Surface to Perforator Index: Assessing the Importance of the Number of Perforators in Successful Harvesting of the Anterolateral Thigh Flap.

INTRODUCTION: The use of perforator flaps has become more popular with improvement of surgical technique, technology, as well as understanding of microvascular anatomy. The selection of well-perfused angiosomes is critical to the successful outcome of patients undergoing free tissue transfer. The number of perforators that are needed is dependent upon the surface area of the flap being harvested; however, there have been no studies to assess the optimal surface area supplied by each perforator. We hypothesized that the smaller the surface area supplied by each perforator correlated with fewer flap-related complications in the harvesting of the anterolateral thigh (ALT) flap. METHODS: All ALT flaps harvested from 2015 to 2021 at our institution were retrospectively reviewed. The surface area of the flap harvested was calculated as A = πab, where a is the long radius and b is the short radius of the ellipse. The surface-perforator index (SPI) was calculated for each flap by dividing the surface area of the ALT flap by the number of perforators supplying the flap. Our primary outcomes were flap-related complications that included: partial flap loss, dehiscence, and venous congestion. RESULTS: A total of 106 patients were identified. Twenty-four patients (22.6%) developed perforator-related complications. An increasing SPI and SPI to body surface area were strongly associated with development of complications (adjusted odds ratio [95% confidence interval], adjusted p: 1.02 [1.01, 1.03], < 0.001and 1.23 [1.12, 1.42], p < 0.001). An SPI of greater than 150 cm2/perforator was associated with a higher probability of complications (p < 0.001). CONCLUSION: Flap-related complications are significantly related to the number of perforators supplying the flap. The smaller the surface area supplied by a single perforator correlates with significantly fewer flap-related complications. SPI is a new index that may be used as a predictive tool to aid in identifying flaps that may be more prone to complications in free tissue transfer.

Not all flaps are created equal: Assessing the impact of active smoking in muscle-only versus perforator flaps for patients undergoing nonelective extremity-free tissue transfer-A case control study.

INTRODUCTION: Active smoking is known to impair wound healing following free tissue transfer for reconstruction due to its vasoconstrictive effect on the microcirculation. The aim of this study was to evaluate the impact of flap selection on flap loss, in nonelective, traumatic extremity-free soft tissue transfer in active smokers. METHODS: All patients undergoing a free tissue transfer for acute trauma of the extremity at a level I trauma center from 2011 to 2017 were identified. Breast reconstruction and osseous/osseocutaneous flaps were excluded. The study population was divided in two groups based on the type of flap used (muscle versus perforator flap). Factors known to be associated with impaired wound healing were extracted from the database. Primary outcome was major smoking related complications (complete/partial flap loss). Secondary outcomes included minor flap-related complications (infection, dehiscence) and donor site complications. The impact of smoking was assessed for the different type of flaps using multivariate analyses. RESULTS: A total of 118 flaps were identified during the study period. Out of those, 52 were perforator-based fasciocutaneous flaps, while 66 were muscle flaps. Active smoking status resulted in a statistically significant increase in the incidence of major and minor complications in the perforator flap group (36% vs. 4%, adjusted odds ratio, AOR [95%CI]: 2.31[1.48,19.30], adj-p = 0.021 and 32% vs. 17%, AOR [95% CI]: 1.23[1.11,14.31], adj-p = 0.034) but had no impact in the muscle group. CONCLUSIONS: The present study suggests a higher incidence of flap related complications in smokers when a perforator flap was selected but no impact when a muscle flap was utilized.

Impact of Blood Transfusion in Free Flap Breast Reconstruction Using Propensity Score Matching.

BACKGROUND: Microvascular thrombosis has been associated with cytokine release and inflammatory syndromes which can occur as a result of blood transfusions. This phenomenon could potentially lead to complications in breast free flap reconstruction. The aim of this study was to evaluate the impact of perioperative blood transfusion in free flap breast reconstruction using large population analysis. METHODS: The American College of Surgeons National Quality Improvement Program database was queried for delayed free flap breast reconstructions performed in 2016. The study population was divided based on perioperative blood transfusion within 24 hours of the start of the operation. Propensity score matching analysis was used to ensure homogeneity between the two study groups. Primary outcome was unplanned return to the operating room (OR) within 30 days. Secondary outcomes were readmission and complications. RESULTS: A total of 1,256 patients were identified. Out of those, 91 patients received a perioperative blood transfusion. All the patients received only one unit of PRBC within the first 24 hours. Those patients were matched with similar patients who did not receive a transfusion on a ratio of 1:3 (273 patients). Patients who received a transfusion had a significantly higher incidence of reoperation (42 vs. 10%, p < 0.001). Patients who received a transfusion were more likely to return to the OR after 48 hours from the initial operation (13 vs. 5%, p = 0.001). All returns to the OR were due to flap-related complications. Perioperative blood transfusion increased the incidence of wound dehiscence (9 vs. 2%, p = 0.041) but had no protective effect on the development of other postoperative complications. CONCLUSION: Perioperative blood transfusion in free flap breast reconstruction is associated with an increased probability of flap-related complications and subsequent return to the OR without decreasing the probability of developing other systemic postoperative complications.

Tissue Oximetry Readings Accurately Predict Late Complications in Patients Undergoing Free Flap Breast Reconstruction: Exploring the Optimal Cut Point Value.

BACKGROUND: The use of tissue oximetry for monitoring following free tissue transfer has become a common practice across the United States to facilitate early detection of poor flap perfusion in the postoperative setting. There is no consensus on the optimal value, below which there is a higher chance of wound complications in patients undergoing free flap breast reconstruction. METHODS: Patients undergoing free flap breast reconstruction from 2015 to 2018 were retrospectively reviewed. Patients who returned to the operating room for a revision of the anastomosis were excluded from analysis. Patients were divided in two groups based on the development of late complications. Those were defined as fat necrosis, wound dehiscence, or distal flap ischemia/necrosis that developed after discharge from the hospital. Mean percutaneous oximetry readings of the first 24 hours were recorded and the mean change from the initial reading was calculated. The correlation between tissue oximetry change and development of complications was explored. RESULTS: A total of 120 patients were identified. The mean age was 53, while the mean body mass index was 33. A total of 38 patients developed late wound complication. History of smoking, diabetes mellitus, neoadjuvant radiation therapy, and the mean change of the tissue oximetry reading were identified as independent predictors of wound complications. The absolute number of the tissue oximetry reading did not predict late complications. A multivariate analysis revealed that patients who experienced a mean decrease < 15% from the initial reading during the first 24 hours were significantly more likely to develop late flap-related wound complications. CONCLUSION: In patients undergoing free tissue breast reconstruction, tissue oximetry readings do not predict late wound complications. However, the mean change at 24 hours from the initial reading does. A decrease of <15% in tissue perfusion was associated with a significant increase in the probability of developing flap-related wound complications.

Development and Validation of a Scoring System to Predict Surgical Site Infection After Ventral Hernia Repair: A Michigan Surgical Quality Collaborative Study.

INTRODUCTION: Surgical site infections (SSIs) are a rare but significant complication following an elective ventral hernia repair. This study aims to develop a risk assessment tool in order to predict the risk of developing SSIs postoperatively. METHODS: All patients undergoing an elective ventral hernia repair were identified using the Michigan Surgical Quality Collaborative (MSQC) database. Patients' demographics, comorbidities and technical aspects of the operations were extracted. Logistic regressions were used to create a predictive scoring system for SSIs. RESULTS: A total of 4983 were included. SSIs occurred in 3.4% of the patient population. A stepwise forward logistic regression identified the need to use drains, BMI, wound classification at the end of the surgery, presence of severe adhesions, a history of CAD, the need for intensive care after surgery, the use of pressors, EtOH abuse and history of PVD as being independently associated with the development of postoperative surgical site infections. CONCLUSION: In patients undergoing an elective hernia repair, the incidence of SSI is low. Several preoperative and perioperative factors can contribute to the development of SSIs.

The Relationship between Age, Common Bile Duct Diameter and Diagnostic Probability in Suspected Choledocholithiasis.

BACKGROUND: Aging has been associated with increasing common bile duct (CBD) diameter and reported as independently predictive of the likelihood of choledocolithiasis. These associations are controversial with uncertain diagnostic utility in patients presenting with symptomatic disease. The current study examined the relationship between age, CBD size, and the diagnostic probability of choledocolithiasis. METHODS: Symptomatic patients undergoing evaluation for suspected choledocolithiasis from January 2008 to February 2011 were reviewed. In the cohort without choledocolithiasis, the relationship between aging and CBD size was examined as a continuous variable and by comparing mean CBD size across stratified age groups. Multivariate analysis examined the relationship between increasing age and diagnostic probability of choledocolithiasis in all patients. RESULTS: Choledocolithasis was diagnosed by MR cholangiopancreatography (MRCP) or endoscopic retrograde (ERCP) in 496 of 1,000 patients reviewed. Mean CBD was 6.0 mm (±2.8 mm) in the 504 of 1,000 patients without choledocolithiasis on ERCP/MRCP. Increasing age had no correlation with CBD size as a continuous variable (r2 = 0.011, p = 0.811). No difference occurred across age groups (Kruskal-Wallis, p = 0.157). Age had no association with diagnostic likelihood of choledocolithiasis (AOR [95% CI] 0.99 [0.98-1.01], adjusted-p = 0.335). CONCLUSION: In a large population undergoing investigation for biliary disease, increasing age was neither associated with increasing CBD diameter nor predictive of the likelihood of choledocolithiasis.

Post-procedural pseudoaneurysms: Single-center experience.

Objectives Pseudoaneurysms are a well-recognized complication of percutaneous angiographic procedures. Ultrasound-guided thrombin injection is currently the preferred treatment modality. This study was undertaken to evaluate our experience with the management of post-procedure pseudoaneurysms. Methods A retrospective study was undertaken of all patients who developed a post-procedure pseudoaneurysm between March 2004 and January 2013. Data were obtained from our prospectively maintained non-invasive vascular laboratory data base. Results Overall, 167 patients (80 men) with post-procedure pseudoaneurysms were identified. The mean age was 66 years. Post-procedure pseudoaneurysms developed following diagnostic coronary angiography (38%), coronary angioplasty (37%), peripheral vascular interventions (14.7%), or other access procedures (7.6%). Mean post-procedure pseudoaneurysm diameter was 2.8 ± 1.8 cm. One hundred forty-two post-procedure pseudoaneurysms were injected with thrombin under ultrasound guidance. Primary success rate was 93.5%. There were 12 (8.5%) procedural failures of which seven (58%) responded to reinjection, three (25%) required operative management, one was treated with ultrasound-guided compression, and one (8.3%) was simply observed. On multivariate analysis, failures were associated with increased aneurysm diameter ( p = 0.006; odds ratio 2.23, 95% CI 1.25 to 3.96), end-stage renal disease ( p = 0.013; odds ratio 1.15, 95% CI 1.09 to 1.78) and superficial femoral artery aneurysm origin ( p = 0.031; odds ratio 0.20, 95% CI 0.04 to 0.86). There were two episodes of thrombus formation in the femoral artery; one resolved with anticoagulation alone, and the other required thrombectomy. Conclusions Percutaneous ultrasound-guided thrombin injection is an effective and safe method for managing post-procedure pseudoaneurysms. Failure rates are low and associated with large aneurysm size, superficial femoral artery origin and end-stage renal disease.

Diabetes Mellitus in Patients Presenting with Adhesive Small Bowel Obstruction: Delaying Surgical Intervention Results in Worse Outcomes.

INTRODUCTION: The impact of diabetes mellitus (DM) on outcomes in patients undergoing emergency laparotomy for adhesive small bowel obstruction (ASBO) remains unknown. METHODS: Low-risk (ASA class of I and II) patients requiring emergency operation for ASBO were identified using the ACS NSQIP database. Propensity score matching was used to match patients with DM to those without DM in a ratio of 1:3. Mortality, infectious complications, acute renal failure (ARF), and myocardial infarction (MI) were compared between the two groups. The impact of delaying OR ≥ 24 h was also analyzed in the two groups. RESULTS: A total of 1,608 patients were matched, 402 with DM and 1,204 without DM. Overall, patients with DM were significantly more likely to develop infections, ARF and MI. Diabetes had no negative impact on outcomes if the operation was performed within 24 h of admission. However, delaying surgery >24, significantly increased infections, ARF and MI. CONCLUSIONS: DM in low-risk patients has no negative impact on outcomes in patients undergoing surgery for ASBO within 24 h. However, delaying surgery >24 h resulted in worse outcomes.

Large animal evaluation of riboflavin and ultraviolet light-treated whole blood transfusion in a diffuse, nonsurgical bleeding porcine model.

BACKGROUND: The Mirasol system has been demonstrated to effectively inactivate white blood cells (WBCs) and reduce pathogens in whole blood in vitro. The purpose of this study was to compare the safety and efficacy of Mirasol-treated fresh whole blood (FWB) to untreated FWB in an in vivo model of surgical bleeding. STUDY DESIGN AND METHODS: A total of 18 anesthetized pigs (40 kg) underwent a 35% total blood volume bleed, cooling to 33°C, and a standardized liver injury. Animals were then randomly assigned to resuscitation with either Mirasol-treated or untreated FWB, and intraoperative blood loss was measured. After abdominal closure, the animals were observed for 14 days, after which the animals were euthanized and tissues were obtained for histopathologic examination. Mortality, tissue near-infrared spectroscopy, red blood cell (RBC) variables, platelets (PLTs), WBCs, and coagulation indices were analyzed. RESULTS: Total intraoperative blood loss was similar in test and control arms (8.3 ± 3.2 mL/kg vs. 7.7 ± 3.9 mL/kg, p = 0.720). All animals survived to Day 14. Trended values over time did not show significant differences-tissue oxygenation (p = 0.605), hemoglobin (p = 0.461), PLTs (p = 0.807), WBCs (p = 0.435), prothrombin time (p = 0.655), activated partial thromboplastin time (p = 0.416), thromboelastography (TEG)-reaction time (p = 0.265), or TEG-clot formation time (p = 0.081). Histopathology did not show significant differences between arms. CONCLUSIONS: Mirasol-treated FWB did not impact survival, blood loss, tissue oxygen delivery, RBC indices, or coagulation variables in a standardized liver injury model. These data suggest that Mirasol-treated FWB is both safe and efficacious in vivo.

Quality and outcomes reporting in trauma using International Statistical Classification for Diseases, Ninth Revision codes.

BACKGROUND: Use of the trauma and injury severity score (TRISS) for quality and outcomes assessment is challenged by the need for laborious collection of demographic and physiological data. We hypothesize that a novel stratification approach based on International Statistical Classification for Diseases, Ninth Revision (ICD-9) data that are readily available for trauma patients provides a more accurate and more easily obtainable alternative to TRISS with the potential for widespread use. METHODS: Data from the ACS National Trauma Data Bank were used to train and evaluate a regularized logistic regression model for mortality and linear regression models for hospital length of stay (HLOS) and intensive care unit length of stay (ILOS) using ICD-9 diagnostic and procedural codes. Model training was performed on data from 2008 (n = 124,625) and evaluation on data from 2009 (n = 120,079). The discrimination and calibration of each model based on ICD-9 codes were compared with those of TRISS. RESULTS: The mortality model using ICD-9 codes was comparable with that of TRISS in terms of the area under the receiver operating characteristic curve (0.922 versus 0.921, P = not significant.) and achieved better results in terms of both integrated discrimination improvement (0.106, P < 0.001) and Hosmer-Lemeshow chi-squared value (294.15 versus 2043.20). The HLOS and ILOS models using ICD-9 codes also demonstrated improvements in both R(2) (0.64 versus 0.30 for HLOS, 0.68 versus 0.34 for ILOS) and root mean-squared error (7.06 versus 8.62 for HLOS, 4.15 versus 9.54 for ILOS). CONCLUSIONS: Use of ICD-9 codes for stratification provides a more accurate and more broadly applicable approach to quality and outcomes assessment in trauma patients than the labor-intensive gold standard of TRISS.

Tobacco Use and Body Mass Index as Predictors of Outcomes in Patients Undergoing Breast Reduction Mammoplasty.

BACKGROUND: Breast reduction mammoplasty accounts for more than 60,000 procedures annually, but the literature is still sparse on outcomes, especially beyond the single institution perspective. The aim of this study was to seek a broader view by study breast reduction outcomes in the National Surgical Quality Improvement Program database. METHODS: The National Surgical Quality Improvement Program data set was queried for the Current Procedural Terminology code 19318 from the years 2005 to 2010. The principal outcomes measured were wound complications, surgical site infections, and reoperations. Univariate and multivariate analysis was performed to identify significant relationships. RESULTS: A total of 2779 patients were identified. The mean age was 42.7 (14.1) years and the mean body mass index (BMI) was 31.6 (7.0) kg/m2. Tobacco use was associated with a higher rate of reoperation (P = 0.02). Body mass index was identified as an independent risk factor for wound complications (odds ratio, 1.85, P = 0.005). Patients with BMI greater than 40 kg/m were significantly more likely to develop postoperative wound complications (P = 0.02). CONCLUSIONS: This study represents the largest sample on breast reduction in the literature. Age and surgeon specialty did not correlate with negative results. In contrast, tobacco use and BMI were associated with worse breast reduction outcomes.

Is prehospital endotracheal intubation associated with improved outcomes in isolated severe head injury? A matched cohort analysis.

INTRODUCTION: Prehospital endotracheal intubation (ETI) following traumatic brain injury in urban settings is controversial. Studies investigating admission arterial blood gas (ABG) patterns in these instances are scant. HYPOTHESIS: Outcomes in patients subjected to divergent prehospital airway management options following severe head injury were studied. METHODS: This was a retrospective propensity-matched study in patients with isolated TBI (head Abbreviated Injury Scale (AIS) ≥ 3) and Glasgow Coma Scale (GCS) score of ≤ 8 admitted to a Level 1 urban trauma center from January 1, 2003 through October 31, 2011. Cases that had prehospital ETI were compared to controls subjected to oxygen by mask in a one to three ratio for demographics, mechanism of injury, tachycardia/hypotension, Injury Severity Score, type of intracranial lesion, and all major surgical interventions. Primary outcome was mortality and secondary outcomes included admission gas profile, in-hospital morbidity, ICU length of stay (ICU LOS) and hospital length of stay (HLOS). RESULTS: Cases (n = 55) and controls (n = 165) had statistically similar prehospital and in-hospital variables after propensity matching. Mortality was significantly higher for the ETI group (69.1% vs 55.2% respectively, P = .011). There was no difference in pH, base deficit, and pCO2 on admission blood gases; however the ETI group had significantly lower pO2 (187 (SD = 14) vs 213 (SD = 13), P = .034). There was a significantly increased incidence of septic shock in the ETI group. Patients subjected to prehospital ETI had a longer HLOS and ICU LOS. CONCLUSION: In isolated severe traumatic brain injury, prehospital endotracheal intubation was associated with significantly higher adjusted mortality rate and worsened admission oxygenation. Further prospective validation of these findings is warranted.

Early operation is associated with a survival benefit for patients with adhesive bowel obstruction.

OBJECTIVE: To evaluate the effect of surgical delay on the outcomes of patients with adhesive small bowel obstruction (ASBO). BACKGROUND: It is generally accepted that patients with uncomplicated ASBO failing nonoperative management should be operated on within 5 days. However, the optimal time of operation within this 5-day period is unknown. METHODS: Patients requiring surgery for ASBO were identified from the National Surgical Quality Improvement Program database. Linear regression was performed to evaluate the impact of incremental surgical delay in mortality and complications. The study population was stratified by time to intervention (24-hour intervals), and logistic regression was performed to adjust for premorbid conditions and presentation physiology. The outcomes included 30-day mortality and infectious complications. RESULTS: A total of 4163 patients underwent laparotomy for ASBO. Mortality and complications increased significantly with operative delay. Delay of 24 hours or more was associated with significantly higher mortality: 6.5% vs 3.0%; adjusted odds ratio (AOR) [95% confidence interval (CI), 1.58 (1.12-2.24)]; P = 0.009. The delayed operation group (≥24 hours) also had significantly higher rates of surgical site infections [12.9% vs 10.0%; AOR (95% CI), 1.33 (1.08-1.62); P = 0.007], pneumonia (7.9% vs 5.2%; AOR (95% CI), 1.36 (1.04-1.78); P = 0.025], sepsis [7.6% vs 5.1%; AOR (95% CI), 1.45 (1.10-1.90); P = 0.007], and septic shock [6.2% vs 3.5%; AOR (95% CI), 1.47 (1.07-2.02); P = 0.018]. Early operation was associated with significantly shorter hospital stay [8.4 ± 8.3 vs 14.4±13.5 days; adjusted mean difference (95% CI), -5.2 (-5.9 to -4.4); P<0.001]. CONCLUSIONS: Early operative intervention for patients with ASBO is associated with a significant survival benefit, lower incidence of local and systemic complications, and shorter hospitalization.

Effect of diabetes on outcomes in patients undergoing emergent cholecystectomy for acute cholecystitis.

BACKGROUND: The purpose of the present study was to determine the prevalence of diabetes and its effect on surgical outcomes in patients undergoing emergent, in-patient cholecystectomy for acute cholecystitis. Some 8.3 % of the U.S. population has diabetes and this number is projected to rise to 21-33 % by 2050. Diabetes is considered to be associated with a higher incidence of acute cholecystitis; however, its impact on outcomes is unknown. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients with acute cholecystitis who underwent emergent in-patient cholecystectomy from 2004 to 2010. The study population was divided into two groups: diabetics and non-diabetics. Diabetics were further subdivided into those taking oral medication and those on insulin. Demographics, co-morbidities, and wound classification were compared with univariate analysis, and 30-day outcomes were compared with univariate and multivariate analyses. RESULTS: A total of 5,460 patients met the inclusion criteria. Of these 770 (14.10 %) had a diagnosis of diabetes. Mortality was higher for diabetics than for non-diabetics [4.4 vs 1.4 %, adjusted odds ratio (AOR) (95 % CI): 1.79 (1.09, 2.94), adj-p = 0.022]. Preoperative perforation rates were 25.1 and 13.0 %, respectively [AOR (95 % CI): 1.34 (1.09, 1.65), adj-p = 0.005]. The adjusted risk of cardiovascular events and renal failure was significantly higher for diabetics. Insulin treatment, but not oral medication, was associated with a significant increase in mortality, preoperative perforation, superficial surgical site infection, septic shock, cardiovascular incidents, and renal insufficiency. CONCLUSIONS: In patients undergoing cholecystectomy for acute cholecystitis, diabetes increases the risk of mortality, cardiovascular events, and renal failure. Insulin-treated diabetics have more co-morbidities and poorer outcomes.

Bridge plating in the setting of radiocarpal instability: Does distal fixation to the second or third metacarpal matter? A cadaveric study.

BACKGROUND: Radiocarpal dislocations are rare but potentially devastating injuries. Poorer outcomes are associated with inadequate or lost reduction, such as ulnar translocation, but no consensus exists on the ideal fixation technique. Dorsal bridge plate fixation has been described for various settings in the treatment of complex distal radius fractures and can be fixed distally to the second or third metacarpal, but its application for radiocarpal dislocations has not been established. AIM: To determine whether distal fixation to the second or third metacarpal matters. METHODS: Using a cadaveric radiocarpal dislocation model, the effect of distal fixation was studied in two stages: (1) A pilot study that investigated the effect of distal fixation alone; and (2) a more refined study that investigated the effect of described techniques for distal and proximal fixation. Radiographs were measured in various parameters to determine the quality of the reduction achieved. RESULTS: The pilot study found that focusing on distal fixation alone without changing proximal fixation results in ulnar translocation and volar subluxation when fixing distally to the second metacarpal compared with the third. The second iteration demonstrated that anatomic alignment in coronal and sagittal planes could be achieved with each technique. CONCLUSION: In a cadaveric radiocarpal dislocation model, anatomic alignment can be maintained with bridge plate fixation to the second metacarpal or the third metacarpal if the described technique is followed. When considering dorsal bridge plate fixation for radiocarpal dislocations, the surgeon is encouraged to understand the nuances of different fixation techniques and how implant design features may influence proximal placement.

Palmar Venous Malformation: A Case Report of a Rare Occurrence and a Treatment Algorithm.

Palmar venous malformations are not well described in the surgical literature and are a therapeutic challenge due to the intricate anatomy of the hand. We present the case of a 19-year-old right-handed female patient from Mexico who was referred to us with a right palmar lesion present since birth, previously diagnosed as a venous malformation. The patient reported that she had undergone sclerotherapy 10 years before in addition to a prior aborted attempt at excision. Venous palmar malformations are rare occurrences. Although an individualized approach is important, the development of an algorithm may assist in the standardization of the treatment of this pathology to preserve the hand's functional status.

Full versus Baby Dose Aspirin for Antithrombotic Prophylaxis in Free Tissue Transfer: Does Size Matter?

The postoperative prophylactic use of aspirin is a common practice among plastic surgeons after free tissue transfer. The use of baby aspirin (81 mg) has become more popular due to previously published literature in other fields. We hypothesized that a full dose daily aspirin is nonsuperior to a baby dose daily aspirin in preventing arterial thrombosis in free tissue transfer. Methods: All patients undergoing free tissue transfer of the extremities from 2008 to 2020 were retrospectively reviewed. They were divided into two groups based on the postoperative dose of aspirin administered (full versus baby dose). The decision to administer full or baby dose was based on the surgeon's preference. Primary outcome was revision of the arterial anastomosis. Secondary outcomes included flap complications. Results: A total of 183 patients were identified. Out of those, 78 patients received full dose aspirin postoperatively, whereas 105 received a baby dose of aspirin. Patients who received baby aspirin did not have a higher incidence of returning to the operating room for revision of their arterial anastomosis [7.6% versus 7.7%; adjusted odds ratio, 0.93 (95% confidence interval, 0.28-3.11); adjusted P, 0.906]. No differences were found between the two groups in complete and partial flap loss, wound dehiscence, or infection. None of the patients experienced any aspirin-related gastrointestinal complications. Conclusions: In patients undergoing free tissue transfer, thrombosis of the arterial anastomosis is rare. Administration of a full dose of aspirin postoperatively was not superior to a baby dose of aspirin in preventing arterial-related complications.

Perioperative Tissue Oximetry-driven Fluid Resuscitation Improves Flap Perfusion in Autologous Free Tissue Breast Reconstruction.

Introduction: The use of tissue oximetry for monitoring following free tissue transfer has become a common practice to facilitate early detection of poor flap perfusion. We hypothesized that T stat readings may guide fluid administration in the postoperative period and improve perfusion in patients undergoing autologous breast reconstruction. Methods: Patients undergoing free flap breast reconstruction from 2015 to 2018 were reviewed. Mean percutaneous oximetry readings of the first four postoperative days were recorded. The mean change at 24 hours from the original reading was calculated (∆TO). The study population was divided in two groups based on whether administration of intravenous fluids (IVFs) was increased/maintained (group 1) or decreased (group 2) after postoperative day 1. Results: A total of 120 patients were identified. The mean age was 53, and mean BMI was 33. Overall, patients for whom fluid administration was decreased experienced an increase in their tissue perfusion, while patient who received a bolus or maintained the same rate of IVF experienced a decrease. Patients who had a negative ∆TO experienced a statistically significant difference between groups 1 and 2 at 24 and 72 hours (-4 versus +3 and -11 versus +13, respectively). For patients with a positive ∆TO, although decreasing fluids resulted in higher readings, it did not reach statistical significance at 24 or 72 hours (0 versus +2 and +4 versus +6, respectively). Conclusions: In patients undergoing free tissue breast reconstruction, tissue oximetry readings may be used as a novel guide for postoperative fluid management.

Flow-through Anterolateral Thigh Flaps: Report of 3 Consecutive Cases and Review of its Utility.

In the field of plastic and reconstructive surgery, soft tissue reconstruction of Gustilo 3B with peripheral vascular disease or 3C fractures is a complex treatment algorithm. The concomitant issue of soft tissue coverage with vascular reconstruction is the main challenge when opting for free tissue transfer. The flow-through flap offers the surgeon the ability to treat a vascular injury or high-grade stenosis to maintain distal perfusion, while also providing soft tissue coverage. In this study, we present a case series of 3 patients who underwent flow-through anterolateral thigh free flap for lower extremity soft tissue coverage. Each patient had a history of trauma and either single vessel runoff or a dominant branch with diminutive secondary blood flow to the foot. All patients successfully underwent free flap reconstruction of lower extremity wounds while concomitantly reconstructing diseased arterial supply. Only 1 patient suffered partial flap loss postoperatively that was treated with debridement and split thickness skin grafting. Flow-through free tissue transfer is a valuable treatment option not only in Gustilo 3C fractures requiring soft tissue coverage, but also in patients with Gustilo 3B fractures with peripheral vascular disease.