The Effect of Variation in Intraoperative Technique on Outcomes in Lower Extremity Free Flap Reconstruction
Year: 2021
Type: article
Study design: Observational Study
Abstract: BACKGROUND: Free flap failure rates are higher in the lower extremity than other areas of the body. Although many studies have investigated the effect of particular intraoperative technical variables, these studies include small case series or are not contemporary cohorts, more closely reflecting current practice with wide availability and acceptance of instruments such as venous couplers and perforator flap techniques. PURPOSE: Investigate the effect of variation in intraoperative techniques and flap selection on flap outcomes in a diverse cohort of patients requiring lower extremity free flap coverage at multiple institutions. METHODS: Consecutive patients undergoing free flap reconstruction of the lower extremity distal to the hip at two level-1 trauma centers from January 1, 2002 to January 1, 2020 were identified using CPT codes followed by review of electronic medical records to collect patient and treatment characteristics. Data were collected regarding patient demographics and comorbidities, indication for operation, intraoperative technical details (including recipient artery and vein, number of venous anastomoses, superficial or deep venous system, coupler use and coupler size, end-to-end and end-to-side anastomosis techniques, use of vein grafts or AV loops), and complications. The primary outcome of interest was flap failure, and secondary outcomes included unplanned return to the operating room, arterial thrombosis, venous thrombosis, and partial flap failure. Bivariate analysis and multivariable logistic regression were performed. RESULTS: 410 patients underwent 420 free tissue transfers to the lower extremity distal to the hip. Median follow up time was 17 months (IQR 8.0–37). Overall, total flap failure occurred in 5.0% (n = 21), partial flap failure in 5.7% (n = 24), and unplanned reoperation in 9.0% (n = 37), arterial thrombosis 3.2% (n = 13), and venous thrombosis 5.4% (n = 22). Regarding intraoperative variables, on bivariate analysis, ALT donor site (P = 0.049) was associated with arterial thrombosis, ankle recipient site (P = 0.046) and prior failed reconstruction (P = 0.003) with partial flap failure, and arterial revision with total flap failure (P = 0.035). Recipient artery, recipient vein, venous system, number of venous anastomoses, and arterial and venous anastomotic technique were not associated with any of the outcomes. On multivariate analysis, only the relationship between intraoperative arterial revision and total flap failure [OR: 4.54, p 0.016, 95% CI (1.3-–16)] and prior failed reconstruction and partial flap failure [OR 2.79, p 0.020, 95% CI (1.2-–6.7)] remained significant. CONCLUSIONS: This retrospective review demonstrates that many options are available to the reconstructive surgeon performing lower extremity reconstruction with free flaps regarding intraoperative technique and flap anatomy that lead to equally high success rates; however, intraoperative revision of the arterial anastomosis portends poorly for ultimate flap success.
Institution: Harvard University
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,195
OpenAlex ID: W4310485605