Robotic deep inferior epigastric perforator flap harvest in breast reconstruction.

INTRODUCTION: Reducing donor site morbidity after deep inferior epigastric artery perforator (DIEP) flap harvest relies mainly upon maintaining integrity of the anterior rectus sheath fascia. The purpose of this study is to describe our minimally-invasive technique for robotic DIEP flap harvest. METHODS: A retrospective review of four patients undergoing seven robotic-assisted DIEP flaps from 2019 to 2020 was conducted. Average patient age and BMI were 52 years (range: 45-60 years) and 26.7 kg/m2 (range: 20.6-32.4 kg/m2 ), respectively. Average follow-up was 6.31 months (range: 5.73-7.27 months). Robotic flap harvest was performed with intramuscular perforator dissection in standard fashion, followed by the transabdominal preperitoneal (TAPP) approach to DIEP pedicle harvest using the da Vinci Xi robot. Data was collected on demographic information, perioperative characteristics. Primary outcomes included successful flap harvest as well as donor site morbidity (e.g., abdominal bulge, hernia, bowel obstruction, etc.). RESULTS: All four patients underwent bilateral abdominally-based free flap reconstruction. Three patients received bilateral robotic DIEP flaps, and one patient underwent unilateral robotic DIEP flap reconstruction. The da Vinci Xi robot was used in all cases. Average flap weight and pedicle length were 522 g (range: 110-809 g) and 11.2 cm (range: 10-12 cm), respectively. There were no flap failures, and no patient experienced abdominal wall donor site morbidity on physical exam. CONCLUSION: While further studies are needed to validate its use, this report represents the largest series of robotic DIEP flap harvests to date and is a valuable addition to the literature.

Early-onset osteoradionecrosis following adjuvant volumetric-modulated arc therapy to an osteocutaneous free fibula flap with customized titanium plate.

BACKGROUND: Computerized surgical planning (CSP) in osseous reconstruction of head and neck cancer defects has become a mainstay of treatment. However, the consequences of CSP-designed titanium plating systems on planning adjuvant radiation remains unclear. METHODS: Two patients underwent head and neck cancer resection and maxillomandibular free fibula flap reconstruction with CSP-designed plates and immediate placement of osseointegrated dental implants. Surgical treatment was followed by adjuvant intensity modulated radiation therapy (IMRT). RESULTS: Both patients developed osteoradionecrosis (ORN), and one patient had local recurrence. The locations of disease occurred at the areas of highest titanium plate burden, possibly attributed to IMRT dosing inaccuracy caused by the CSP-designed plating system. CONCLUSION: Despite proven benefits of CSP-designed plates in osseous free flap reconstruction, there may be an underreported risk to adjuvant IMRT treatment planning leading to ORN and/or local recurrence. Future study should investigate alternative plating methods and materials to mitigate this debilitating outcome.

Double-Barrel Versus Single-Barrel Fibula Flaps for Mandibular Reconstruction: Safety and Outcomes.

OBJECTIVES/HYPOTHESIS: Fibula flaps are routinely used for osseous reconstruction of head and neck defects. However, single-barrel fibula flaps may result in a height discrepancy between native mandible and grafted bone, limiting outcomes from both an aesthetic and dental standpoint. The double-barrel fibula flap aims to resolve this. We present our institution's outcomes comparing both flap designs. STUDY DESIGN: Retrospective cohort study. METHODS: We conducted a retrospective review of all patients undergoing free fibula flap mandibular reconstruction at our institution between October 2008 and October 2020. Patients were grouped based on whether they underwent single-barrel or double-barrel reconstruction. Postoperative outcomes data were collected and compared between groups. Differences in categorical and continuous variables were assessed using a Chi-square test or Student's t-test, respectively. RESULTS: Out of 168 patients, 126 underwent single-barrel and 42 underwent double-barrel reconstruction. There was no significant difference in postoperative morbidity between approaches, including total complications (P = .37), flap-related complications (P = .62), takeback to the operating room (P = .75), flap salvage (P = .66), flap failure (P = .45), and mortality (P = .19). In addition, there was no significant difference in operative time (P = .86) or duration of hospital stay (P = .17). After adjusting for confounders, primary dental implantation was significantly higher in the double-barrel group (odds ratio, 3.02; 95% confidence interval, 1.2-7.6; P = .019). CONCLUSION: Double-barrel fibula flap mandibular reconstruction can be performed safely without increased postoperative morbidity or duration of hospital stay relative to single-barrel reconstruction. Moreover, the double-barrel approach is associated with higher odds of primary dental implantation and may warrant further consideration as part of an expanded toolkit for achieving early dental rehabilitation. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1576-1581, 2022.

Single Versus Double Venous Anastomosis Microvascular Free Flaps for Head and Neck Reconstruction.

ABSTRACT: Venous congestion accounts for most microvascular free tissue flaps failures. Given the lack of consensus on the use of single versus dual venous outflow, the authors present our institutional experience with 1 versus 2 vein anastomoses in microvascular free flap for head and neck reconstruction. A retrospective chart review was performed on all patients undergoing free flaps for head and neck reconstruction at our institution between 2008 and 2020. The authors included patients who underwent anterolateral thigh, radial forearm free flap, or fibula free flaps. The authors classified patients based on the number of venous anastomoses used and compared complication rates. A total of 279 patients with a mean age of 55.11 years (standard deviation 19.31) were included. One hundred sixty-eight patients (60.2%) underwent fibula free flaps, 59 (21.1%) anterolateral thigh, and 52 (18.6%) radial forearm free flap. The majority of patients were American Society of Anesthesiologists classification III or higher (N = 158, 56.6%) and had history of radiation (N = 156, 55.9%). Most flaps were performed using a single venous anastomosis (83.8%). Univariate analysis of postoperative outcomes demonstrated no significant differences in overall complications (P = 0.788), flap failure (P = 1.0), return to the Operating Room (OR) (P = 1.0), hematoma (P = 0.225), length of hospital stay (P = 0.725), or venous congestion (P = 0.479). In our cohort, the rate of venous congestion was not statistically different between flaps with 1 and 2 venous anastomoses. Decision to perform a second venous anastomoses should be guided by anatomical location, vessel lie, flap size, and intraoperative visual assessment.

Free-Flap Reconstruction for Diabetic Lower Extremity Limb Salvage.

BACKGROUND: Microsurgical free tissue transfer is an important treatment option for nonhealing lower extremity diabetic wounds. The purpose of this study was to identify factors that affect flap survival and wound complications. METHODS: A retrospective review was conducted of 806 lower extremity free-flap reconstructions performed from 1979 to 2016. A total of 33 free flaps were used for coverage of nonhealing lower-extremity diabetic ulcers. Primary outcome measures were perioperative complications and long-term wound breakdown. RESULTS: The average age was 54 ± 12.3 y. 15.2% of patients were smokers, 12.1% had coronary artery disease and 12.1% had end-stage renal disease. Muscle flaps predominated (75.8%) compared to fasciocutaneous flaps (24.2%). There were 7 patients (21.2%) that underwent a revascularization procedure before (71.4%) or at the same time (28.6%) as the free flap. Immediate complications occurred in 7 flaps (21.2%) with 4 partial losses (12.1%) and 3 total flap failures (9.1%). Major wound complications occurred in 18.2% of patients. An end-to-side (E-S) anastomosis for the artery was used in 63.6% (n = 22) of flaps compared with an end-to-end (E-E) anastomosis. E-S anastomosis was associated with a significantly lower risk of wound complications compared with an arterial E-E anastomosis (0% versus 45.5%, P = 0.001). CONCLUSIONS: The use of microvascular free flaps can be used successfully to cover lower-extremity diabetic wounds. E-E arterial anastomosis should be avoided if possible as it is associated with higher rates of wound breakdown, likely by impairing perfusion to a distal limb with an already compromised vasculature. LEVEL OF EVIDENCE: Level III.

Larger free flap size is associated with increased complications in lower extremity trauma reconstruction.

BACKGROUND: Free flap reconstruction after lower extremity trauma remains challenging with various factors affecting overall success. Increasing defect and flap size have been demonstrated to be a surrogate for overall injury severity and correlated with complications. In addition, larger free flaps that encompass more tissue theoretically possess high metabolic demand, and may be more susceptible to ischemic insult. Therefore, the purpose of our study was to determine how flap size affects microsurgical outcomes in the setting of lower extremity trauma reconstruction. METHODS: Retrospective review of 806 lower extremity free flap reconstructions performed from 1979 to 2016 among three affiliated hospitals: a private university hospital, Veterans Health Administration Hospital (VA), and a large, public hospital serving as a level 1 trauma center for the city. Soft tissue free flaps used for below the knee reconstructions of traumatic injuries were included. A receiver operating curve (ROC) was generated and Youden index was used to determine the optimal flap size for predicting flap success. Based on this, flaps were divided into those smaller than 250 cm2 and larger than 250 cm2 . Partial flap failure, total flap failure, takebacks, and overall major complications (defined as events involving flap compromise) were compared between these two groups. Multivariate logistic regression was performed to determine whether flap size independently predicts complications and flap failures, controlling for injury-related and operative factors. RESULTS: A total of 393 patients underwent lower extremity free tissue transfer. There were 229 flaps (58.2%) with size <250 cm2 and 164 flaps (41.7%) ≥ 250 cm2 . ROC analysis and Youden index calculation demonstrated 250 cm2 (AUC 0.651) to be the cutoff free flap for predicting increasing flap failure. Compared to flaps with less than 250 cm2 , larger flaps were associated with increased major complications (33.6% vs. 50.0%, p = .001), any flap failure (11.8% vs. 25.0%, p = .001) and partial flap failure (4.8% vs. 14.6%, p = .001). Logistic regression analysis controlling for age, flap type, era of reconstruction, number of venous anastomoses, presence of associated injuries, presence of a bone gap, vessel runoff, and flap size identified increasing flap size to be independently predictive of major complications (p = .05), any flap failure (p = .001), partial flap failure (p < .001), and takebacks (p = .03). Subset analysis by flap type demonstrated that when flap size exceeded 250 cm2 , use of muscle flaps was associated with significantly increased flap failure rates (p = .008) while for smaller flap size, there was no significant difference in complications between muscle and fasciocutaneous flaps. CONCLUSION: Increasing flap size is independently predictive of flap complications. In particular, a flap size cutoff value of 250 cm2 was associated with significantly increased flap failure and complications particularly among muscle-based flaps. Therefore, we suggest that fasciocutaneous flaps be utilized for injuries requiring large surface area of soft tissue reconstruction.

Risk factors for microvascular free flaps in pediatric lower extremity trauma.

PURPOSE: There is a dearth of literature dedicated to specifically evaluating the use of free flap reconstruction in pediatric lower extremity traumas. This study aims to identify specific risk factors for flap failure in pediatric lower extremity trauma reconstruction. METHODS: Retrospective review of 53 free flaps in our lower extremity database (1979-2017) identified all free flaps performed for traumatic reconstruction in children <18 years of age at our institution. RESULTS: Fifty-three free flaps (11.1%) were performed in 49 pediatric patients. The majority of patients were male (69.8%). Arterial injury was present in 19 patients (35.8%) and was associated with significantly higher flap failure rates compared to patients without arterial injury (36.8% vs 8.8%, P = 0.020) with RR = 6.0. This was again found to be true on multivariable logistic regression controlling for age, sex, flap type, and degree of arterial or venous mismatch (RR = 53, P = 0.016). Analysis of anastomotic vessel sizes revealed significantly increased risk of flap failure with increasing degree of arterial size mismatch on logistic regression (RR = 6.1, p = .02). Similar analysis for venous data was performed and revealed trending towards similar findings without reaching statistical significance (P = .086); however, the presence of any venous size mismatch was associated with significantly increased risk of flap failure on χ2 analysis (P = 0.041). CONCLUSION: Free flap reconstruction in the pediatric trauma population is safe with similar survival outcomes when compared to the adult population. Arterial injury and vessel size mismatch were associated with significantly higher flap failure rates in this population. LEVEL OF EVIDENCE: Level III.

Reconstruction of Gustilo Type IIIC Injuries of the Lower Extremity.

BACKGROUND: Gustilo type IIIC open tibia fractures are characterized by an ischemic limb requiring immediate arterial repair. In this patient population, the decision between primary amputation and limb salvage can be challenging. This study aims to evaluate the reconstructive outcomes of patients with Gustilo type IIIC injuries. METHODS: A single-center retrospective review of 806 lower extremity free flaps from 1976 to 2016 was performed. Flap loss and salvage rates for patients with Gustilo type IIIC injuries were determined. To determine the utility of performing salvage in this group, outcomes of the IIIC reconstructions were compared to those of similar patients with Gustilo I type IIB injuries with only a single patent vessel. RESULTS: A total of 32 patients with Gustilo type IIIC injuries underwent reconstruction after traumatic injury. Ten patients (31.3 percent) experienced a perioperative complication, including seven unplanned returns to the operating room (21.9 percent), three partial flap losses (9.4 percent), and five complete flap losses (15.6 percent). When type IIIC injuries were compared with single-vessel Gustilo type IIIB injuries, no statistically significant differences were noted with respect to major perioperative complications (p = 0.527), unplanned return to the operating room (p = 0.06), partial flap loss (p = 0.209), complete flap loss (p = 0.596), or salvage rate (p = 0.368). Although this result was not statistically significant, Gustilo type IIIC injuries trended toward lower take-back rates and higher salvage rates compared with single-vessel Gustilo type IIIB injuries. CONCLUSION: Patients with Gustilo type IIIC open tibia fractures should be considered candidates for limb salvage, as flap loss and reconstruction of these injuries are comparable to those of the routinely reconstructed single-vessel runoff type IIIB injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm.

BACKGROUND: Marko Godina, in his landmark paper in 1986, established the principle of early flap coverage for reconstruction of traumatic lower extremity injuries. The aim of this study was to determine how timing influences outcomes in lower extremity traumatic free flap reconstruction based on Godina's original findings. METHODS: A retrospective review identified 358 soft-tissue free flaps from 1979 to 2016 for below knee trauma performed within 1 year of injury. Patients were stratified based on timing of coverage: 3 days or less (early), 4 to 90 days (delayed), and more than 90 days (late). The delayed group was further divided into two groups: 4 to 9 days and 10 to 90 days. Flap outcomes were examined based on timing of reconstruction. RESULTS: Flaps performed within 3 days after injury compared with between 4 to 90 days had decreased risk of major complications (OR, 0.40, p = 0.04). A receiver operating curve demonstrated day 10 to be the optimal day for predicting flap success. Flaps performed less than or equal to 3 days versus 4 to 9 days had no differences in any flap outcomes. In contrast, flaps performed within 4 to 9 days of injury compared to within 10 to 90 days were associated with significantly lower total flap failure rates (relative risk, 0.29, p = 0.025) and major complications (relative risk, 0.37, p = 0.002). CONCLUSIONS: Early free flap reconstruction performed within 3 days of injury had superior outcomes compared with the delayed (4 to 90 day) group, consistent with Godina's original findings. However, as an update to his paradigm, this ideal early period of reconstruction can be safely extended to within 10 days of injury without an adverse effect on outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Vein Size Mismatch Increases Flap Failure in Lower Extremity Trauma Free Flap Reconstruction.

BACKGROUND: Venous outflow problems are the most common reasons for perioperative flap complications. Size mismatch in venous anastomoses poses a theoretical problem by promoting turbulent flow and subsequent thrombus formation. The purpose of this study was to determine if increased vein size mismatch is predictive of flap failure. METHODS: Retrospective review of our institutional flap registry from 1979 to 2016 identified 410 free flaps performed for reconstruction of lower extremity trauma. Patient demographics, flap characteristics, and flap outcomes were examined. Venous size mismatch was defined as a difference in size ≥ 1 mm between the recipient vein and flap vein. RESULTS: Vein size mismatch ≥ 1mm was present in 17.1% (n = 70) of patients. The majority of anastomoses were end-to-end (n = 379, 92.4%), and end-to-side anastomoses were preferentially used in the presence of vein size mismatch (p < 0.001). Major complications occurred in 119 (29%) flaps, with 35 (8.5%) partial flap losses and 34 (8.3%) total flap losses. Looking specifically at flaps with end-to-end venous anastomoses, venous size mismatch was associated with increased total flap failure (p = 0.031) and takeback for vascular compromise (p = 0.030). Recipient vein size relative to flap vein size (larger or smaller) had no effect on flap outcomes. Multivariable regression analysis controlling for age, sex, flap type, number of veins, recipient vein size, flap vein size, venous coupler use, and vein size mismatch demonstrated that flaps with ≥ 1 mm vein mismatch were predictive of total flap failure (p = 0.045; odds ratio: 2.58). CONCLUSION: Flaps with vein size mismatch ≥ 1 mm demonstrated increased flap complication rates in the setting of end-to-end venous anastomoses. End-to-side anastomosis was preferentially used in vein size mismatch and carried a higher risk of flap failure. Our results support using veins of similar size for anastomosis whenever feasible to protect against flap complications.

Comparing Outcomes for Fasciocutaneous versus Muscle Flaps in Foot and Ankle Free Flap Reconstruction.

BACKGROUND: The distal lower extremity poses unique reconstructive challenges due to its requirements for durability of the load-bearing plantar surface and for thin, pliable contour in the dorsal foot and ankle region. This study compares outcomes between muscle and fasciocutaneous flaps in patients with foot and ankle defects. METHODS: A retrospective review of soft tissue free flaps used for traumatic foot and ankle defects was performed. Outcomes included takebacks, partial flap failure, total flap failure, and wound complications. RESULTS: A total of 165 cases met inclusion criteria, with muscle flaps (n = 110) comprising the majority. Defects involving the non-weight-bearing surface were more common (n = 86) than those of the weight-bearing surface (n = 79). Complications occurred in 56 flaps (33.9%), including 11 partial losses (6.7%) and 6 complete losses (3.6%). There were no differences in take backs, partial flap failure, or total flap failure between muscle and fasciocutaneous flaps; however, fasciocutaneous flaps had significantly fewer wound complications compared with muscle flaps (7.3% vs. 19.1%, p = 0.046). On multivariable regression analysis, defects of the weight-bearing surface had significantly increased risk of wound breakdown compared with those in the non-weight-bearing surface (odds ratio: 5.05, p = 0.004). CONCLUSION: Compared with fasciocutaneous flaps, muscle flaps demonstrated higher rates of wound complications. While the flap selection in foot and ankle reconstruction depends on the nature of the defect, our findings support the use of fasciocutaneous over muscle flaps in this region.

Comparing Reconstructive Outcomes in Patients with Gustilo Type IIIB Fractures and Concomitant Arterial Injuries.

BACKGROUND: The Gustilo classification serves as a proxy for injury severity, but recent data suggest rising complications with decreasing arterial runoff. This study aims to compare different microsurgical anastomosis options based on the number of patent vessels in the lower extremity. METHODS: A single-center retrospective review of 806 lower extremity free flaps performed from 1976 to 2016 was performed. Patients with Gustilo type IIIB injuries were grouped based on the number of patent vessels in the leg (three, two, or one). Patients were compared based on the type of anastomosis performed, evaluating for perioperative complications and flap failures. RESULTS: Perioperative complications occurred in 111 flaps (27 percent): 71 take-backs (17 percent), 45 partial losses (11 percent), and 37 complete losses (9 percent). Among patients with three-vessel runoff (61.8 percent), there was no difference in take-backs or flap loss between those with end-to-end versus end-to-side anastomoses. In 68 patients (18.7 percent) with two-vessel runoff, no difference between take-backs or flap loss was noted when comparing any anastomosis (i.e., end-to-end into an injured vessel, end-to-end into an uninjured vessel, or end-to-side into an uninjured vessel), although vein grafts were required more often in the end-to-side groups (p < 0.01). Finally, in 39 patients (10.7 percent) with single-vessel runoff, no difference was seen between end-to-end anastomosis into an injured vessel or end-to-side anastomosis into an uninjured vessel in terms of take-backs or flap loss. CONCLUSION: Higher rates of flap failure correlated with decreasing numbers of patent vessels in the leg, but neither type of microvascular anastomosis nor vessel selection demonstrated any impact on reconstructive outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Survival after Digit Replantation and Revascularization Is Not Affected by the Use of Interpositional Grafts during Arterial Repair.

BACKGROUND: Interpositional grafts can be used to reconstruct the digital artery during revascularization and replantation when primary repair is not possible. The purpose of this study was to determine the effect of using interpositional grafts on the rate of digit survival. METHODS: A retrospective review of all patients from 2007 to 2016 that required revascularization and/or replantation of one or more digits was performed. RESULTS: One hundred twenty-seven patients were identified with 171 affected digits (118 digital revascularizations and 53 digital replantations). A graft was used to repair the digital artery in 50 percent of revascularizations (59 of 118) and in 49 percent of replantations (26 of 53). There was no difference in digit survival with use of an interpositional graft for arterial repair versus primary repair in revascularization (91.5 percent in both groups) or replantation (48.1 percent versus 46.2 percent; p = 0.88). Regression analysis demonstrated no association between the use of interpositional grafts and digit survival. Interpositional grafting was more likely to be used in crush (62.5 percent) and avulsion injuries (72.2 percent) compared with sharp laceration injuries (11.1 percent), with a relative risk of 5.6 (p = 0.01) and 6.5 (p = 0.006), respectively. CONCLUSIONS: There was no difference in the survival rate of amputated digits that required interpositional grafting for arterial repair. The need for an interpositional graft in a large zone of injury should not be considered a contraindication to performing revascularization or replantation. Furthermore, hand surgeons should have a low threshold for using interpositional grafts, especially in crush or avulsion injuries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Quantifying outcomes for leech therapy in digit revascularization and replantation.

We retrospectively reviewed 201 digit replantations or revascularizations that were performed between August 2007 and June 2015. Leeching therapy was used in 48 digits and was more commonly required in replanted digits. In revascularized digits, leeching was used significantly more frequently in avulsion injuries and injuries associated with fractures. Digits that were leeched for more than 4.5 days had significantly higher rates of survival of digits after replantation or revascularization. Leeching was associated with higher incidence of transfusion, higher mean number of transfusions, and longer length of stay. We conclude from this study that leeching is used more frequently after digital replantation than revascularizaion, and in revascularized digits, leeching is used more often in avulsion injury and in patients with fractures. In patients requiring leeching therapy, leaching for more than 4.5 days leads to higher rate of digital survival. Level of evidence: IV.

Comparison of Hand-Sewn versus Coupled Venous Anastomoses in Traumatic Lower Extremity Reconstruction.

BACKGROUND: Microvascular reconstruction of the lower extremity has the highest reported complication and flap failure rates of any anatomical region. Despite widespread adoption of the mechanical anastomotic venous coupler and encouraging results in other anatomical regions, there are limited reports examining its use in the lower extremity. This study compares outcomes between coupled and hand-sewn venous anastomoses in traumatic lower extremity reconstruction. METHODS: Retrospective review of our institutional flap registry from 1979 to 2016 identified soft tissue free flaps performed for the reconstruction of Gustilo type IIIB/IIIC open tibial fractures. Patient demographics, flap characteristics, use of a venous anastomotic coupler, and perioperative outcomes were examined. Analysis was performed using chi-square and Student's t-tests. RESULTS: A total of 361 patients received a microvascular free flap for coverage of a Gustilo type IIIB or IIIC tibial fracture following traumatic injury. After excluding cases that lacked adequate information on coupler use, 358 free flaps were included in the study. There were 72 (20%) free flaps performed using a venous coupler and 286 (80%) performed with hand-sewn venous anastomoses. There were comparable rates of major complications (22.2 vs. 26.1%; p = 0.522), total flap failure (6.5%, vs. 10.2%; p = 0.362), and partial flap failure (9.7 vs. 12.2%; p = 0.579) between venous coupler and hand-sewn anastomoses, respectively. Furthermore, use of the venous coupler was not associated with increased rates of operative take backs (22.8 vs. 23.0%; p = 0.974). However, reconstructions performed using a venous coupler were significantly more likely to have a second venous anastomosis performed (37.5 vs. 21.3%; p = 0.004). CONCLUSION: Complication and flap failure rates were similar between reconstructions performed with a venous coupler and those performed with hand-sewn venous anastomoses. These findings suggest that use of the venous anastomotic coupler is safe and effective in lower extremity reconstruction, with comparable outcomes to conventional sutured anastomoses.

Skin Paddles Improve Muscle Flap Salvage Rates After Microvascular Compromise in Lower Extremity Reconstruction.

PURPOSE: Free tissue transfer after lower extremity trauma is associated with notoriously high complication rates. Theoretically, the inclusion of a cutaneous paddle on muscle free flaps may improve clinical flap monitoring. The effect of skin paddle presence on muscle free flap salvage outcomes after take-back was examined. METHODS: Retrospective query of our institutional free-flap registry (1979-2016) identified 362 muscle-based flaps performed for soft tissue coverage after below-knee trauma. Primary outcome measures were perioperative complications, specifically take-back indications, timing, and flap salvage rates. Univariate and multivariate regression analyses were performed where appropriate. RESULTS: The most common flaps were latissimus dorsi (166; 45.9%), rectus abdominis (123; 34%), and gracilis (42; 11.6%) with 90 flaps (24.9%) including skin paddles. Take-backs for vascular compromise occurred in 44 flaps (12.2%), of which 39% contained a skin paddle while 61% did not. Overall salvage rate was 20.5%, with 31.8% partial failures and 47.7% total flap losses. Muscle flaps with skin paddles were more likely to return to the operating room within 48 hours postoperatively than those without (57.1% vs 18.2%, P = 0.036). After take-back, significantly more muscle flaps with skin paddles were salvaged compared with muscle flaps without paddles (35.7% vs 4.5%, P = 0.024). Similarly, more muscle-only flaps after take-back failed compared with their counterparts with skin paddles (95.5% vs 65.3%, P = 0.024). CONCLUSIONS: Muscle flaps with a cutaneous paddle were associated with earlier return to the operating room and more successful flap salvage after take-back compared with muscle-only flaps. These findings suggest that skin paddle presence may improve clinical flap monitoring and promote recognition and treatment of microvascular compromise in lower extremity reconstruction.

Forty Years of Lower Extremity Take-Backs: Flap Type Influences Salvage Outcomes.

BACKGROUND: Considering that muscle has higher metabolic demand than fasciocutaneous tissue and can be more difficult to monitor clinically, the authors compared take-back salvage rates between fasciocutaneous and muscle free flaps for lower extremity trauma reconstruction. METHODS: The authors conducted a retrospective review of 806 free flaps (1979 to 2016); 481 soft-tissue flaps performed for below-knee trauma met inclusion criteria. Primary outcome measures were perioperative complications, specifically, take-backs and flap salvage rates. Univariate and multivariate regression analysis was performed where appropriate. RESULTS: Take-backs occurred in 71 flaps (muscle, n = 44; fasciocutaneous, n = 27) at an average of 3.7 ± 5.4 days postoperatively. Indications were venous (48 percent), arterial (31 percent), unknown (10 percent), and hematoma (10 percent). Overall outcomes were complete salvage (37 percent), partial failure (25 percent), and total failure (38 percent). Take-backs occurring within 48 hours postoperatively correlated with higher salvage rates (p = 0.022). Fasciocutaneous flaps demonstrated increased take-back rates compared with muscle flaps (p = 0.005) that more frequently occurred within 48 hours postoperatively (relative risk, 13.2; p = 0.012). Fasciocutaneous flaps were successfully salvaged more often than muscle-based flaps (p < 0.001). Multivariable regression strongly demonstrated higher risk of take-back failure for muscle flaps (relative risk, 9.42; p = 0.001), despite higher take-back rates among fasciocutaneous flaps (relative risk, 2.28; p = 0.004). CONCLUSIONS: Compared with muscle-based flaps, fasciocutaneous flaps demonstrated earlier and more frequent take-backs for suspected vascular compromise, with higher successful take-back salvage rates. Furthermore, muscle flaps with skin paddles also demonstrated better salvage outcomes than those without. These findings may reflect a combination of lower metabolic demand and easier visual recognition of vascular compromise in fasciocutaneous tissue. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Evolving Presence of Women in Academic Plastic Surgery: A Study of the Past 40 Years.

BACKGROUND: Among surgical subspecialties, plastic surgery holds the highest percentage of women, and, the female contingent of board-certified plastic surgeons and trainees has grown steadily. However, their academic impact has been underestimated. We present the academic footprint of female plastic surgeons over the past 40 years. METHODS: A list of female plastic surgeons currently active at, and retired from, Accreditation Council for Graduate Medical Education-accredited plastic surgery residency programs was compiled. Each surgeon was searched on PubMed to gather their total number of publications, journals, and topics of research after completion of training. Date of publication and 5-year impact factor for each journal were recorded. Publications were organized into 10-year periods (1976 to 1985, 1986 to 1995, 1996 to 2005, and 2006 to 2016). RESULTS: One hundred fifty-five currently active and 80 retired academic female plastic surgeons were identified, who published 2982 articles in 479 peer-reviewed journals. The average 5-year impact factor was 4.093. The number of publications increased with each decade: 37 (1976 to 1985), 218 (1986 to 1995), 472 (1996 to 2005), and 2255 (2006 to 2016). The most commonly published areas were hand/nerve (22 percent), craniofacial (21 percent), and breast (20 percent). Over time, publications in hand/nerve research decreased (76, 60, 38, and 14 percent, respectively); craniofacial-related publications increased (8, 11, 18, and 23 percent, respectively); and publications in breast research increased (0, 8, 9, and 24 percent, respectively). The 2006 to 2016 period yielded the most even distribution of research topics. CONCLUSION: The academic contribution of female plastic surgeons has substantially increased in number and has become more evenly distributed across subspecialty topics.

Proximal versus Distal Recipient Vessels in Lower Extremity Reconstruction: A Retrospective Series and Systematic Review.

BACKGROUND: Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. We investigated the impact of recipient vessel location on free flap outcomes. METHODS: Retrospective review (1979-2016); 312 soft tissue free flaps for open tibia fractures met inclusion criteria. Flap characteristics and perioperative outcomes were examined. Systematic review identified articles evaluating anastomosis location and flap outcomes; pooled data analysis was performed. RESULTS: More anastomoses were performed proximal to the zone of injury (80.7%) than distal (19.3%). Distal anastomoses were not associated with increased take back rates (19.6%) compared with proximal (23.8%) anastomoses (p = 0.356). Regression analysis comparing proximal and distal anastomoses found no difference in partial flap failures (7.4% vs 11.9%; p = 0.978) or total flap failures (9.3% vs 9.3%; p = 0.815) when controlling for the presence of arterial injury, flap type, and time from injury to coverage. Systematic review yielded 11 articles with 1,245 proximal and 127 distal anastomoses for comparison. Pooled analysis (p = 0.58) and weighted comparative analysis (p = 0.39) found no difference in flap failure rates between proximal and distal groups. CONCLUSION: Our results are congruent with the current lower extremity literature and demonstrate no difference in perioperative complication rates between anastomoses performed proximal or distal to the zone of injury. These findings suggest that anastomotic location choice should be based primarily on recipient vessel quality/flow and ease of access/exposure rather than orientation relative to the zone of injury.