Background: Reconstructive microsurgery is an effective limb-saving option for nonhealing lower extremity wounds in diabetic patients. However, the ability to predict the future need for amputation is unclear. This article seeks to identify risk factors for amputation following microsurgical free tissue transfer in the diabetic lower extremity. Methods: Diabetic patients undergoing lower extremity free flap surgery between August of 2011 and January of 2018 performed by a single surgeon were identified retrospectively. Patient comorbidities, reconstructive conditions and flap traits, microsurgical outcomes, and long-term outcomes were examined. Variables conferring risk for future amputation were examined by means of regression analysis. Results: Sixty-four patients met the criteria. The overall immediate flap success rate was 94 percent (60 of 64). Long term, 50 patients (78.1 percent) underwent successful salvage, and 14 patients (21.9 percent) required major amputation. Acute flap loss resulted in four amputations, and delayed complications (hematoma, infection, recurrent nonhealing) resulted in 10 amputations. The average time to amputation was 5.6 months. Risk factors for amputation were end-stage renal disease (OR, 30.7; p = 0.0087), hindfoot wounds (OR, 4.6; p = 0.020), elevated hemoglobin A1C level greater than 8.4 percent (OR, 1.4; p = 0.05), and positive wound cultures (OR, 6.1; p = 0.003). Conclusions: Multiple comorbidities and poor glucose control were identified as risk factors for amputation after free flap limb salvage. However, successful limb preservation is possible. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Background There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation. Methods In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population. Results The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease. Conclusion Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.

Ear molding can improve the majority congenital ear deformities when employed early after birth. However, the best time to initiate treatment remains debated. In describing one surgeon's experience over the past near decade, this study aims to highlight differences conferred by treatment timing. The authors hypothesize that auricular outcomes are superior when deformities are molded beginning in the first 3 weeks of life. A retrospective review (2010–2018) of 272 cases was performed to compare early initiation of molding (<3 weeks of birth) and delayed initiation (>3 weeks). The mean patient age was 20.4 days and the mean follow-up was 0.5 months. The overall treatment was approximately 31 days. The number of devices required was similar (2.3 versus 2.5) between early and delayed molding cases, but fall-outs (1.0 versus 0.7, P = 0.02) and replacements (0.9 versus 0.6, P = 0.004) were more common after delayed molding. Skin complications developed in 13.6% (37) of ears overall and did not differ by treatment timing. Follow-up surgery was reported in 2 (0.7%) ears. The 85% of families reported subjective satisfaction with the final outcome; satisfaction was significantly higher for early cases (97% versus 79%, P = 0.03). Ear molding of congenital ear deformities should begin within 3 weeks of birth. From our experience, setting realistic expectations helps limit discrepancies between expectation and outcome.

Background: Limb salvage techniques using free tissue transfer in patients with chronic wounds caused by longstanding osteomyelitis, diabetes, and peripheral vascular disease are technically challenging. The longitudinal slit arteriotomy end-to-side anastomosis is the authors’ preferred technique because it is the least invasive arteriotomy and is especially important for diseased recipient arteries. The authors reviewed highly comorbid patients who underwent free tissue transfer with this technique to understand the success rates, overall outcomes, and long-term limb salvage rates. Methods: A retrospective review was performed to analyze outcomes of free tissue transfer using longitudinal slit arteriotomy end-to-side anastomosis between 2012 and 2018 performed by the senior surgeon (K.K.E.). Results: One hundred fifteen free flaps were identified. Patients were, on average, 55.9 years old, with a body mass index of 29.2 kg/m2. Comorbidities included osteomyelitis (83.5 percent), hypertension (60.9 percent), tobacco use (46.1 percent), diabetes (44.3 percent), peripheral vascular disease (44.3 percent), hypercoagulability (35.7 percent), and arterial calcifications (17.4 percent). Overall flap success was 93.0 percent; 27.8 percent required reoperation perioperatively because of complications. On univariate analysis, diabetes mellitus, hypertension, and hypercoagulability were significantly associated with eventual amputation (p < 0.05). Multivariate analysis showed that intraoperative thrombosis and take back was independently associated with flap failure. There was an overall limb salvage rate of 83.5 percent, and of those salvaged, 92.7 percent were ambulating without a prosthesis at a mean follow-up of 1.53 years. Conclusions: This is the largest series of longitudinal slit arteriotomy end-to-side anastomosis for patients undergoing free tissue transfer for limb-threatening defects in the compromised host. Overall flap success, limb salvage rates, and functional outcomes are high using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.