American Association of Plastic Surgeons

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Lessons Learned From 40 Years of Traumatic Lower Extremity Free Flaps: Inflow, Outflow, Takebacks, and Failures
John T. Stranix, MD1, Z-Hye Lee, MD1, Adam Jacoby, MD1, Lavinia Anzai, MD1, Joseph A. Ricci, MD1, William J. Rifkin, BA1, Tomer Avraham, MD2, Vishal D. Thanik, MD1, Pierre B. Saadeh, MD1, Jamie P. Levine, MD1.
1New York University Langone Health, New York, NY, USA, 2Yale University School of Medicine, New Haven, CT, USA.

PURPOSE: Despite advances in microsurgery, higher lower extremity complication rates have persisted. We evaluated our experience to identify factors associated with microsurgical outcomes. METHODS: Retrospective review of 806 flaps (1976-2016); 481 soft tissue flaps for below knee trauma met inclusion criteria. Primary outcome measures were perioperative flap complications. RESULTS: Muscle flaps predominated (75%) over fasciocutaneous (25%); major perioperative complications occurred in 111 flaps (23%): 71 takebacks (15%); 45 partial losses (9%); 37 complete losses (8%). Time to coverage: <10 days (33%), 11-90 days (35%), and >90 days (32%). The acute period demonstrated higher failure rates (p=0.007). A learning curve occurred with more takebacks (p=0.033) and failures (p=0.038) among our first 160 flaps. Decreasing arterial runoff directly correlated with increased complications (p=0.048): compared to 3-vessel legs, 2-vessel had increased flap failures (RR=2.08,p=0.041), and 1-vessel had even higher failure risk (RR=3.67,p=0.001). Two veins reduced complications (p=0.042), but subgroup analysis showed no effect on fasciocutaneous flap outcomes. Two-vein muscle flaps, however, had fewer complications (RR=0.37,p=0.001) and flap failures (RR=0.36,p=0.017). Vein size mismatch >1mm increased total failure risk (RR=2.28,p=0.041). Fasciocutaneous flaps had higher takeback rates than muscle (p=0.004); more frequently within 48 hours postoperatively (p=0.012). However, more fasciocutaneous takebacks were successfully salvaged than muscle-based flaps (RR=9.42,p=0.001). Similarly, musculocutaneous flaps were taken back earlier (p=0.036) and salvaged more often (p=0.024) than muscle-only flaps. CONCLUSION: Lower extremity trauma reconstruction remains challenging and should be tailored to each individual patient. Our experience highlights multiple microsurgical factors associated with perioperative outcomes; their demonstrated prognostic value warrants reconstructive consideration.


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