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Evaluating Outcomes in Lower Extremity Free Flap Reconstruction
Nisha Parmeshwar MD1, Feyisayo Ojute BS1, Justin Cheng MD1, Esther Kim MD1 1University of California, San Francisco, Division of Plastic Surgery, San Francisco, CA

Background: Large lower extremity defects pose a challenge to the reconstructive surgeon due to the diversity of causes and approaches. Potential etiologies include trauma, cancer, vascular or diabetic wounds, orthopedic infections and each case must be individually considered to ensure post-operative success. These patients often have multiple comorbidities or concurrent injuries further increasing their operative risks. We present our 5 year institutional experience managing complex lower extremity wounds with microvascular free flap coverage, with the goal of highlighting key patient, preoperative, and post operative factors associated with flap outcomes.

Methods: A retrospective review of all patients who underwent lower extremity free flap reconstruction from 2014-2019 was performed. Preoperative and surgical characteristics were recorded in addition to number of procedures prior to free flap coverage and days to coverage. Complications included flap loss, return to OR, infection, venous congestion, arterial thrombosis.

Results: 112 lower extremity free flaps were reviewed, including 51 free rectus abdominus, 31 anterolateral thigh, 14 gracilis, 5 latissimus dorsi, 10 radial forearm, and 1 temporoparietal fascial free flap. Etiologies included trauma, cancer resection, or other non-healing wounds (orthopedic, podiatric, vascular, DM, IVDU, pressure injury). The mean days from injury or creation of defect to flap coverage was 115.7 days, with the largest mean time to flap in the ALT cohort (84.7 days). The mean number of procedures prior to flap was 3.9. There was no significant difference between flap types with regards to complications, but there were significantly more returns to OR for the other non-healing wound group (56.3%) compared to traumatic (25%) and oncologic (21.4%) (p=0.034). These non-healing wounds were also associated with significantly more delay to flap, with mean of 404 days, relative to 76 and 70 in the trauma and cancer groups respectively (p=0.016). For trauma related free flaps when controlling for patient age, time to flap, and type of flap, for every one increase in prior procedure, there was 2x the odds of venous congestion (p=0.008), 1.8x odds of flap loss (p=0.014), and 1.6x odds of return to OR (p=0.002).

Conclusion: Our results show no significant difference between chosen flap types with regards to free flap outcomes, but free flap coverage of non-healing wounds unrelated to trauma or cancer showed high association with return to OR despite increased delay to flap coverage. In the trauma cohort, there were significant associations with increased number of prior procedures and complications when correcting for delay in time to flap, which would suggest delay does not significantly contribute to outcome in this group.

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