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.

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.

Reverse Sural Adipofascial Flaps with Acellular Dermal Matrix and Negative-Pressure Wound Therapy.

The reverse sural adipofascial flap (RSAF) is used to reconstruct challenging wounds of the foot and ankle. It offers several advantages over the traditional reverse sural flap, including less venous congestion. To complete the reconstruction, split-thickness skin grafting (STSG) may be done immediately or in a delayed fashion; however, both scenarios result in suboptimal take rates and prolonged healing. An acellular dermal matrix (ADM; Integra; Ethicon Inc, Somerville, New Jersey) and negative-pressure wound therapy (NPWT) combined with RSAF followed by delayed STSG may decrease wound healing time.In this study, 8 patients underwent reconstruction of lower-extremity wounds with RSAF. Four patients underwent RSAF with immediate STSG, and 4 underwent RSAF with placement of the ADM and a vacuum-assisted closure device, with STSG at a later date.The 4 patients who underwent RSAF and immediate STSG had an average time to heal of 141.2 days, and 2 patients required reoperation. The 4 patients who underwent RSAF with an ADM and NPWT had an average time to heal of 104.5 days, and 1 patient required reoperation. Average time until STSG was 41.5 days. The latter group demonstrated a reduction in time to heal by an average of 36.7 days, or 25%. All 8 patients achieved successful wound closure.The RSAF is a durable option for complex lower-extremity reconstruction. Interim placement of ADM and NPWT may increase STSG take rates. Using this technique in conjunction with RSAF may decrease the overall healing time compared with RSAF with immediate STSG.

The Periosteal Medial Femoral Condyle Free Flap: A New Option for Soft Tissue Reconstruction of the Distal Lower Extremity.

BACKGROUND: Small (<30 cm) soft tissue defects of the distal leg, foot, and ankle pose a complicated issue with regard to wound healing. Multiple flaps have been proposed for reconstruction of these wounds with varying levels of success. The medial femoral condyle flap is a free bone flap supplied by the descending geniculate artery. It is currently used in the treatment of fracture nonunion, infected bone defects, avascular necrosis, and osteoradionecrosis. This study proposes the use of the periosteal portion of the medial femoral condyle (PMFC) flap for soft tissue reconstruction of the distal leg, foot, and ankle. METHODS: We performed a single-center, retrospective series of 6 patients with distal leg, foot, and ankle wounds. All patients underwent reconstruction using the PMFC flap. RESULTS: Of the 6 patients, 5 had chronic wounds. There were no incidences of flap loss. Five patients healed without complication, four of which had undergone immediate skin grafting, whereas one had concomitant skin paddle reconstruction. The remaining patient required a second surgery with a rotation flap for recurrent osteomyelitis and wound infection 2 months after the initial surgery. Mean operative time decreased after a 2-case learning curve. CONCLUSIONS: Small wounds of the distal extremity can be difficult to treat, with many requiring free or rotational flap coverage. We propose novel use of the PMFC flap for reconstruction of small soft tissue defects of the distal leg, foot, and ankle. In our series, we demonstrated no donor site morbidity, with excellent cosmetic and functional outcomes.

Liquid Rhinoplasty.

Soft tissue filler injections have become the second most common noninvasive cosmetic procedure performed in the United States, accounting for roughly 26% of all noninvasive procedures. As experience with filler injections has increased, so too have the applications and uses throughout the face. The popularity of "liquid," or nonsurgical, rhinoplasty has grown considerably with both patients and surgeons over the last decade. First documented in 2006, numerous descriptions of technique and application have grown in tandem with the increasing popularity of nonsurgical rhinoplasty procedures. Although nasal injections remain an "off-label" use in the United States, hyaluronic acid fillers have gained multiple applications for the nose. These include, but are not limited to, leveling a dorsal hump through the addition of volume above and below the dorsal convexity, filling of visible nasal concavities, correcting upper and middle third asymmetries, as well as improving the under-rotated or under the projected tip. Though attractive to both patient and surgeon for various reasons, nasal filler injections are not without risk, and knowledge of nasal surgical anatomy and management of complications are critical for safe, viable outcomes.

Liquid Rhinoplasty.

Soft tissue filler injections have become the second most common noninvasive cosmetic procedure performed in the United States, accounting for roughly 26% of all noninvasive procedures. As experience with filler injections has increased, so too have the applications and uses throughout the face. The popularity of "liquid," or nonsurgical, rhinoplasty has grown considerably with both patients and surgeons over the last decade. First documented in 2006, numerous descriptions of technique and application have grown in tandem with the increasing popularity of nonsurgical rhinoplasty procedures. Although nasal injections remain an "off-label" use in the United States, hyaluronic acid fillers have gained multiple applications for the nose. These include, but are not limited to, leveling a dorsal hump through the addition of volume above and below the dorsal convexity, filling of visible nasal concavities, correcting upper and middle third asymmetries, as well as improving the under-rotated or under the projected tip. Though attractive to both patient and surgeon for various reasons, nasal filler injections are not without risk, and knowledge of nasal surgical anatomy and management of complications are critical for safe, viable outcomes.

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.

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.

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.

Telemedicine and Plastic and Reconstructive Surgery: Lessons from the COVID-19 Pandemic and Directions for the Future.

Telemedicine holds vast amounts of potential in changing the way outpatient plastic and reconstructive surgery is practiced. Before the coronavirus disease 2019 (COVID-19) pandemic, video conferencing was used by a small fraction of medical specialties. However, since the start of the pandemic, the Centers for Medicare and Medicaid Services and the largest private health insurance companies have relaxed regulations to allow the majority of specialties to use video conferencing in lieu of in-person visits. Most importantly, video conferencing minimizes patient and physician exposure in situations such as these, and decreases risk in the immunocompromised population. Video conferencing, which has been shown to be just as safe and efficacious in treating patients, offers the ability to follow up with physicians while saving travel time and travel-related expenses. This in turn correlates with increased patient satisfaction. Video conferencing also allows physicians to expand their reach to patients in rural areas seeking advanced professional advice. Incorporating video conferencing into existing practices will make for a more efficient practice, improve patient satisfaction, and decrease cost to patients and the health care system.

Development and Validation of Scoring System to Predict Secondary Amputations in Free Flap Reconstruction.

Need for amputation is a potential complication when limb salvage is attempted. The present study aimed to develop a risk assessment tool to predict the risk of future amputation when counseling patients about their reconstructive options. METHODS: All patients undergoing a free flap lower extremity soft tissue reconstruction by the senior author from 2005 to 2019 were retrospectively identified. Patient's demographics, comorbidities, and technical aspects of the operation were extracted. Logistic regressions were used to create a predictive scoring system for future amputation. RESULTS: A total of 277 patients were identified. Of these patients, two-thirds (183) were used to derive the scoring system and one-third (94) were used to validate the score. In total, 25 of 183 patients (14%) underwent an amputation. A stepwise forward logistic regression identified age > 55 years, smoking, acute wound, aggressive fluid resuscitation intra-operatively, inability to use a superficial vein for drainage, and inability to use the posterior tibialis artery for anastomosis as independent predictors of need for future amputations. The beta co-efficients were used to create the scoring system, and the patients were categorized into mild, moderate, and severe risk based on their cumulative score. The validity of the scoring system was verified by using the one-third validation cohort. CONCLUSIONS: In patients undergoing free flap reconstruction of the lower extremity, the need for future amputation is 14%. The use of a scoring system can guide the surgeon's and patient's decision regarding limb salvage.