Long-Term Outcome after Successful Lower Extremity Free Flap Salvage

Abstract

Background Vascular occlusion after free flap surgery has become a rare complication but still poses a major challenge. It necessitates urgent re-exploration, but the logistic challenge to provide sufficient resources for the emergency intervention remains. The aim of this study was to analyze the long-term outcome after successful lower extremity free flap salvage. Methods A single-center retrospective study including long-term follow-up was approved by the local ethics committee. From January 1999 to December 2010, a total of 581 free flaps were performed for lower extremity reconstruction. Eighty-six flaps required emergency re-exploration, of which 65 could be salvaged. Fifteen salvaged flaps were excluded from the study because of secondary amputation. Of 50 patients, 29 (6 females and 23 males) were eligible for follow-up. The mean follow-up time was 54.5 ± 32.9 months. Health-related quality of life (Short Form 36 [SF-36]) and scar quality (Vancouver Scar Scale [VSS]) were analyzed. Results The overall flap survival rate was 94.7% and the total loss rate was 5.3%. The re-exploration rate was 14.8% (86 of 581 flaps). The salvage rate was 75.6% (65 of 86 flaps). Twenty-one free flaps were totally lost (24.4%). Partial flap loss occurred in 12 cases (14.0%); 67.5% of the vascular complications occurred during the first 24 hours, 20.9% between 24 and 72 hours, and 11.6% after more than 72 hours. The mean time from the first signs of impaired flap perfusion to re-exploration was 1.3 ± 0.4 hours, and from free tissue transfer to re-exploration was 16.2 ± 1.9 hours. The overall scar appearance was good with an average VSS score of 4.0 points. The average SF-36 physical component score was 54.4 ± 5.4 and the mental component score was 63.1 ± 10.7. Conclusion Careful monitoring and the opportunity for urgent re-exploration are the key to success for free flaps salvage. Following these principles, an acceptable long-term outcome can be achieved.

Microsurgical reconstruction of extensive lower extremity defects with the conjoined parascapular and latissimus dorsi free flap

“…Free flap complication rates are higher in lower extremity reconstruction compared with other recipient sites (Culliford IV et al, 2007). We recently reviewed our experience with 581 lower extremity free flap reconstructions over an 11-year period and found a re-exploration rate of 15% and a flap loss rate of 5% (Bigdeli et al, 2019), which is in line with the literature (Disa, Pusic, Hidalgo, & Cordeiro, 2001;Ho et al, 2012). Regarding the postoperative course of the CPLD free flaps, we found a re-exploration rate of 13% for microvascular complications and a flap loss rate of 5% and thus comparable to single-flap procedures (Bigdeli et al, 2019;Disa et al, 2001;Ho et al, 2012).…”

“…We recently reviewed our experience with 581 lower extremity free flap reconstructions over an 11-year period and found a re-exploration rate of 15% and a flap loss rate of 5% (Bigdeli et al, 2019), which is in line with the literature (Disa, Pusic, Hidalgo, & Cordeiro, 2001;Ho et al, 2012). Regarding the postoperative course of the CPLD free flaps, we found a re-exploration rate of 13% for microvascular complications and a flap loss rate of 5% and thus comparable to single-flap procedures (Bigdeli et al, 2019;Disa et al, 2001;Ho et al, 2012). Thus, transfer of the CPLD free flap may even reduce the risk of microvascular complications, when compared to transferring two individual free flaps.…”

Microsurgical Reconstruction of the Lower Extremity

“…Flap choice does not seem to make much difference in long-term outcome. 7,9,17,18 Most studies would agree that the deciding factor in outcome is the severity of the injury rather than the choices made in reconstruction.…”

Perioperatives Management in der Mikrochirurgie – Konsensus-Statement der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße

“…Bei einer lappenplastischen Rekonstruktion im Extremitätenbe reich handelt es sich mittlerweile um ein sicheres mikrochirurgi sches Verfahren mit einer Lappenplastiküberlebensrate zwischen 94 % und 99 % [16,17]. In der Literatur zeigt sich zentrumsabhängig bei freien lappenplastischen Deckungen an der unteren Extremität eine Revisionsrate von ca.…”

“…Von diesen 15 % revidierten Lappen plastiken konnten wiederum 76 % durch eine Revisionsoperation erhalten werden. 67 % der Revision fanden in den ersten 24 Stun den, 21 % zwischen 24 und 72 Stunden postoperativ und 12 % spä ter statt [17]. In den meisten Fällen handelte es sich um eine ve nöse Thrombose, gefolgt von Hämatom oder Blutungen.…”