The Role of Local Flaps in Foot and Ankle Reconstruction: An Assessment of Outcomes Across 206 Patients with Chronic Wounds.

BACKGROUND: Reconstructive surgery has experienced a paradigm shift in favor of free flaps. Yet, local flaps may be of particular use in foot and ankle reconstruction among comorbid patient populations. Thus, we sought to better characterize long-term outcomes in this setting. METHODS: A single-center, retrospective cohort study of patients undergoing local muscle and fasciocutaneous flaps of the foot and ankle from January 2010-November 2022 was performed. Flap were performed on wounds measuring 3x6cm or smaller, and flap selection depended on preoperative vascular assessment, Doppler findings, comorbidity profile, and wound location, depth, and geometry. RESULTS: Two-hundred and six patients met inclusion criteria. Median age was 61.0 years (IQR 16.8), and comorbidities included diabetes mellitus (DM; n=149/206, 72.3%) and peripheral arterial disease (PAD; n=105/206, 51.0%). Presentations included chronic, non-healing wounds (n=77/206, 39.1%) or osteomyelitis (n=45/206, 22.8%), and most frequently extended to the bone (n=128/206, 62.1%). Eighty-seven patients (n=87/206, 42.2%) received muscle flaps, while 119 received fasciocutaneous flaps (n=119/206, 57.8%). Six patients (n=6/206, 2.9%) necessitated return to the operating room, with thrombosis occurring in two cases (n=2/206, 1.0%). Flap success rate was 98.1%. By a median follow-up duration of 21.7 months (IQR 39.0), 45 patients (n=45/206, 21.8%) necessitated ipsilateral amputation, 73% (n=145/199) were ambulatory, and two deaths were related to the operated wound (n=2/49, 4.1%). Multivariate analysis revealed positive predictors of complications included DM, end-stage renal disease, and prior histories of venous thromboembolism or smoking. CONCLUSION: Local flaps remain a reliable option to reconstruct smaller defects of the foot and ankle in a highly comorbid population.

New and Recurrent Ulcerations after Free Tissue Transfer with Partial Bony Resection in Chronic Foot Wounds within a Comorbid Population.

BACKGROUND: Chronic foot wounds often require bony resection; however, altering the tripod of the foot carries a risk of new ulcer development nearing 70%. Resulting defects often require free tissue transfer (FTT) reconstruction; outcomes data for various bony resection and FTT options may guide clinical decision-making regarding bone and soft-tissue management. The authors hypothesized that alteration of the bony tripod will increase risk of new lesion development after FTT reconstruction. METHODS: A single-center retrospective cohort analysis of patients undergoing FTT from 2011 through 2019 with bony resection and soft-tissue defects of the foot was performed. Data collected included demographics, comorbidities, wound locations, and FTT characteristics. Primary outcomes were recurrent lesion (RL) and new lesion (NL) development. Multivariate logistic regression and Cox hazards regression were used to produce adjusted odds ratios and hazard ratios. RESULTS: Sixty-four patients (mean age, 55.9 years) who underwent bony resection and FTT were included. Mean Charlson Comorbidity Index was 4.1 (SD 2.0), and median follow-up was 14.6 months (range, 7.5 to 34.6 months). Wounds developed after FTT in 42 (67.1%) (RL, 39.1%; NL, 40.6%). Median time to NL development was 3.7 months (range, 0.47 to 9.1 months). First-metatarsal defect (OR, 4.8; 95% CI, 1.5 to 15.7) and flap with cutaneous component (OR, 0.24; 95% CI, 0.07 to 0.8) increased and decreased odds of NL development, respectively. CONCLUSIONS: First-metatarsal defects significantly increase NL risk after FTT. The majority of ulcerations heal with minor procedures but require long-term follow-up. Soft-tissue reconstruction with FTT achieves success in the short term, but NL and RL occur at high rates in the months to years after initial healing. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Risk-Stratified Anticoagulation Protocol Increases Success of Lower Extremity Free Tissue Transfer in the Setting of Thrombophilia.

BACKGROUND: Optimal perioperative thromboprophylaxis is crucial to avoid flap thrombosis and achieve high rates of microsurgical success. At the authors' institution, implementation of a risk-stratified anticoagulation (AC) protocol preliminarily showed a reduction in postoperative thrombotic events and flap loss. The authors present an updated analysis of surgical outcomes using risk-stratified AC in thrombophilic patients who underwent free tissue transfer (FTT) reconstruction for nontraumatic lower extremity (LE) wounds. METHODS: The authors retrospectively reviewed patients who underwent FTT to an LE from 2012 to 2021. Their risk-stratification AC protocol was implemented in July of 2015. Low-risk and moderate-risk patients received subcutaneous heparin. High-risk patients received heparin infusion titrated to a goal partial thromboplastin time of 50 to 70 seconds. Before July of 2015, nonstratified patients were treated with either subcutaneous heparin or low-dose heparin infusion (500 U/hour). Patients were divided into two cohorts (nonstratified and risk-stratified) based on date of FTT reconstruction. Primary outcomes included rates of postoperative complications, flap salvage, and flap success. RESULTS: Two hundred nineteen hypercoagulable patients who underwent FTT to an LE were treated with nonstratified ( n = 26) or risk-stratified ( n = 193) thromboprophylaxis. The overall flap success rate was 96.8% ( n = 212). Flap loss was lower among risk-stratified patients (1.6% versus 15.4%; P = 0.004), which paralleled a significant reduction in postoperative thrombotic events (2.6% versus 15.4%; P = 0.013). Flap salvage was accomplished more often in the risk-stratified cohort (80% versus 0%; P = 0.048). Intraoperative anastomotic revision (OR, 6.10; P = 0.035) and nonrisk stratification (OR, 9.50; P = 0.006) were independently associated with flap failure. CONCLUSIONS: Hypercoagulability can significantly affect microsurgical outcomes. Implementation of a risk-stratified AC protocol can significantly improve flap outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Saphenous Vein Interposition Grafts in Lower Extremity Reconstruction: Appraisal of Technique and Case Series.

Vascular microanastomosis is technically challenging in patients with calcified recipient and donor vessels. Inside-to-outside suturing can prevent plaque rupture and ensure full-thickness intimal approximation. Although this is the preferred technique for anastomosis of atherosclerotic vessels, direct connection of calcified arteries necessitates outside-to-inside suturing on one side of the anastomosis. Furthermore, it is difficult to achieve optimal vessel wall approximation in the setting of luminal size mismatch and rigid vasculature. We previously reported on the use of a saphenous vein interposition graft as a novel technique to achieve a flow-sparing anastomosis in patients with diffuse atherosclerosis who are undergoing free tissue transfer. This study further assesses outcomes of this technique in a series of patients and demonstrates a flap success rate of over 93% in patients with calcified recipient and donor microvasculature.

Expanding Criteria for Limb Salvage in Comorbid Patients with Nonhealing Wounds: The MedStar Georgetown Protocol and Lessons Learned after 200 Lower Extremity Free Flaps.

BACKGROUND: Lower extremity salvage in the setting of nonhealing wounds requires a multidisciplinary approach for successful free tissue transfer. Patients with comorbidities including diabetes mellitus and peripheral vascular disease were previously considered poor candidates for free tissue transfer. However, amputation leads to functional decline and severely increased mortality. The authors present their institutional perioperative protocol in the context of 200 free tissue transfers performed for lower extremity salvage in a highly comorbid population. METHODS: The authors reviewed an institutional database of 200 lower extremity free tissue transfers performed from 2011 to 2019. Demographics, comorbidities, wound cause and location, intraoperative details, flap outcomes, and complications were compared between the first and second 100 flaps. The authors document the evolution of their institutional protocol for lower extremity free tissue transfers, including standard preoperative hypercoagulability testing, angiography, and venous ultrasound. RESULTS: The median Charlson Comorbidity Index was 3, with diabetes mellitus and peripheral vascular disease found in 48 percent and 22 percent of patients, respectively. Thirty-nine percent of patients tested positive for more than three hypercoagulable genetic conditions. The second group of 100 free tissue transfers had a higher proportion of patients with decreased vessel runoff (35 percent versus 47 percent; p < 0.05), rate of endovascular intervention (7.1 percent versus 23 percent; p < 0.05), and rate of venous reflux (19 percent versus 64 percent; p < 0.001). Flap success (91 percent versus 98 percent; p < 0.05) and operative time (500 minutes versus 374 minutes; p < 0.001) improved in the second cohort. CONCLUSIONS: Standardized evidence-based protocols and a multidisciplinary approach enable successful limb salvage. Although there is a learning curve, high levels of salvage can be attained in highly comorbid patients with improved institutional knowledge and capabilities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Long Term Follow-up of Composite Flaps for Single-stage Reconstruction of Concomitant Tendon and Soft Tissue Defects.

Tendon rupture in the setting of significant soft tissue loss poses a challenging reconstructive situation, which requires (1) recreating a stable gait cycle, (2) reducing shear forces and re-rupture risk, and (3) providing adequate soft tissue coverage. In this study, we outline our experience with composite flaps in single-step reconstruction of various lower extremity tendinous injuries with soft tissue loss. METHODS: A retrospective review of all patients requiring free tissue transfer at our tertiary wound care center between 2011 and 2020 was performed. Patients undergoing single-stage free tissue transfer for both soft tissue coverage and tendon reconstruction were selected. Variables of interest included demographics, comorbid conditions, baseline functionality, reconstructive details, and wound characteristics. Outcomes of interest were flap success, return to ambulation, time to ambulation, and postoperative complications. RESULTS: Nineteen patients were included in this study. Patients were on average 48.0 years old (SD 16.5), with a median Charlson Comorbidity Index of 1.00 (IQR: 0.0-2.5). Defects were most often on the ankle (n = 1 3, 68.4%), with extension to the foot or leg in six of these cases. Median wound size was 68.0 cm2 (IQR: 48.0-120.0). The most common tendon requiring reconstruction was the Achilles (n = 13, 68.4%). An anterolateral thigh flap with attached fascia lata extension rolled into a neotendon was used in all 19 cases. At baseline, all patients were ambulatory. Only one patient (5.3%) required return to the operating room for suspected vascular compromise. At a median of 14.4 months (IQR: 8.5-40.5), all 19 patients were ambulatory. CONCLUSIONS: Simultaneous reconstruction of tendinous injuries and soft tissue defects can be readily achieved via composite free flaps. Although other methods of reconstruction can be considered for smaller soft tissue and tendon loss, this approach has significant utility for patients with large defects and yields robust return to preinjury functionality.

Should Antiplatelet Therapy Be Withheld Perioperatively? The First Study Examining Outcomes in Patients Receiving Dual Antiplatelet Therapy in the Lower Extremity Free Flap Population.

BACKGROUND: Antiplatelet agents are typically withheld perioperatively because of bleeding concerns. Dual antiplatelet therapy, such as aspirin and clopidogrel, has significant morbidity and mortality benefits in patients with ischemic heart disease or peripheral vascular disease. This study aims to evaluate the impact of perioperative dual antiplatelet therapy in the lower extremity free tissue transfer population. METHODS: Lower extremity free tissue transfers performed by the senior author (K.K.E.) from 2011 to 2019 were retrospectively reviewed. Demographics, comorbidities, perioperative dual antiplatelet therapy, and free tissue transfer characteristics were recorded. Outcomes of interest included flap success, hematoma formation, blood transfusion requirements, and cardiac event occurrence. RESULTS: One hundred ninety-five free tissue transfers were included. Median age at the time of free tissue transfer was 56.5 years. Median Charlson Comorbidity Index was 3. Thirty-four patients were on clopidogrel, which was either withheld (n = 20) or continued (n = 14) on the day of free tissue transfer. Incidence of blood transfusion was significantly higher in both the withheld and continued versus nonclopidogrel groups. Flap success was statistically equivalent between groups (withheld, 90.0 percent; continued, 92.9 percent; nonclopidogrel, 95.0 percent; p = 0.346). Cardiac events occurred most often in the continued group (21.4 percent) compared to the withheld (5.0 percent) and nonclopidogrel (0.6 percent) groups. On multivariate analysis, holding clopidogrel remained significant for increased odds of postoperative transfusion. The clopidogrel group was no longer significant for intraoperative transfusion. CONCLUSIONS: Despite increases in volume of blood products transfused, free tissue transfer can be performed safely with perioperative dual antiplatelet therapy. Withholding dual antiplatelet therapy on the day of free tissue transfer was not associated with decreased intraoperative transfusion; thus, dual antiplatelet therapy can safely be continued throughout the operative course to minimize cardiovascular risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A single-center experience with head-to-toe microsurgical reconstruction in bloodless medicine patients.

Patients who decline blood transfusions, including members of the Jehovah's Witness faith, often face challenges when they require or desire prolonged operations such as free tissue transfer (FTT). This study aims to outline our institution's experience with treating bloodless medicine patients and offers the first anatomically comprehensive evaluation of FTT in this population. All patients undergoing FTT from 2017 to 2020 at a single institution were retrospectively reviewed. Patients who declined blood products were selected. Outcomes of interest include flap success, operative complications, and changes to hemoglobin measurements. Ten patients undergoing 11 FTT procedures were identified. Average age was 62.4 years (SD 7.6). Most patients were female (n = 9) and Black (n = 8). Average body mass index was 31.3 (SD 5.6), American Society of Anesthesiologists Physical Status was 2.9 (SD 0.5), and Charlson Comorbidity Index was 3.8 (SD 1.1). Sites of FTT reconstruction were breast (6), lower extremity (3), and scalp (2). Average operative time was 390 min (SD 85.1), with an average estimated blood loss of 170 mL (SD 100.4). The difference between preoperative hemoglobin to first postoperative hemoglobin measurement averaged 2.2 g/dL (SD 1.4). Average patient follow-up was 12 months (SD 7.8). Flap success occurred in 10 cases. One patient with flap failure was successfully reconstructed with a second procedure. Despite a small, heterogeneous cohort, our success rate in this highly comorbid population indicates that FTT can be performed effectively for patients who cannot use blood products. Bloodless medicine protocols are beneficial to providers serving patients with transfusion restrictions and systems that strive to limit transfusion volume and risk.

Management of complex surgical wounds of the back: identifying an evidence-based approach.

BACKGROUND: Postoperative dehiscence and surgical site infection after spinal surgery can carry serious morbidity. Multidisciplinary involvement of plastic surgery is essential to minimizing morbidity and achieving definitive closure. However, a standardized approach is lacking. The aim of this study was to identify effective reconstructive interventions for the basis of an evidence-based management protocol. METHODS: A retrospective review was performed at a single tertiary institution for 45 patients who required 53 reconstruction procedures with plastic surgery for wounds secondary to spinal surgery from 2010 to 2019. Statistical analysis was performed for demographics, comorbidities, and treatment methods. Primary outcomes were postoperative complications, including dehiscence, seroma, and infection. The secondary outcome was time to healing. RESULTS: The overall complication rate was 32%, with dehiscence occurring in 17%, seroma in 15% and infection in 11% of cases. Median follow-up was 10 months (interquartile range, 4-23). Use of antibiotic beads did not affect rate of infection occurrence after wound closure (P=0.146). Use of incisional negative pressure wound therapy (iNPWT) was significant for reduced time to healing (P=0.001). Patients treated without iNPWT healed at median of 67.5 days while the patients who received iNPWT healed in 33 days. Demographics and comorbidities between these two groups were similar. CONCLUSIONS: This data provides groundwork for an evidence-based approach to soft tissue reconstruction and management of dehiscence after spinal surgery. Timely involvement of plastic surgery in high-risk patients and utilization of evidence-based interventions such as iNPWT are essential for improving outcomes in this population.

Risk Factors for Loss to Follow-Up in the Lower Extremity Limb Salvage Population.

BACKGROUND: Limb salvage for chronic lower extremity wounds requires long-term care best delivered by specialized multidisciplinary centers. This optimizes function, reduces amputation rates, and improves mortality. These centers may be limited to urban/academic settings, making access and appropriate follow-up challenging. Therefore, the authors hypothesize that both system- and patient-related factors put this population at exceedingly high risk for loss to follow-up. METHODS: Records were reviewed retrospectively for 200 new patients seen at the Georgetown Center for Wound Healing in 2013. The primary outcome was loss to follow-up, defined as three consecutive missed appointments despite explicit documentation indicating the need for return visits. Demographic, clinical, and geographic data were compared. Multivariate logistic regression analysis for loss to follow-up status controlled for variables found significant in the bivariate analysis. Spatial dependency was evaluated using variograms. RESULTS: Over a 6.5-year-period, 49.5 percent of patients followed were lost to follow-up. Male sex and increased driving distance to the limb salvage center were risk factors for loss to follow-up. Wound-specific characteristics including ankle and knee/thigh location were also associated with higher rates of loss to follow-up. There was no spatial dependency or discrete clustering of at-risk patients. CONCLUSIONS: This study is the first of its kind to investigate the demographic and clinical characteristics that predispose chronic lower extremity wound patients to loss to follow-up. These findings inform stakeholders of the high rates of loss to follow-up and support decentralized specialty care, in the form of telemedicine, satellite facilities, and/or dedicated case managers. Future work will focus on targeting vulnerable populations through focused interventions to reduce patient and system burden. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Incidence of Complications in Chest Wall Masculinization for the Obese Female-to-Male Transgender Population: A Case Series.

BACKGROUND: Chest masculinization is aimed at aligning physical appearance of female-to-male (FtM) transgender patients to their identifying gender. Despite limited evidence, obese FtM patients have historically been denied this procedure due to concerns of complications. We reviewed chest masculinization in the high body mass index (BMI) population to analyze the outcomes. METHODS: A Medstar system single surgeon retrospective case review was performed of all FtM patients who underwent chest masculinization from Jan 2018 to Dec 2019 with a BMI greater than 30 kg/m2. Primary outcomes were mastectomy-site complications. RESULTS: Twenty-seven obese FtM patients who underwent bilateral chest masculinization were identified. Mean BMI was 39.2 kg/m2 (SD 5.2). Preoperatively, the majority of patients had a cup size of D or larger (77.3%) and grade 3 ptosis (80.0%). Overall rate of complications was 31.5% at median follow-up of 2.1 months. Individual complications included: partial nipple graft loss 18.5%, total nipple graft loss 5.6%, seroma 3.7%, hematoma 3.7%, infection 2.9%. No complications necessitated return to the operating room. However, the majority of patients (77.8%) were completely satisfied with their aesthetic outcome. CONCLUSION: Mastectomy can be safely performed for chest masculinization in obese FtM patients. The rate of acute complications is comparable to that of non-obese patients despite a mean BMI near 40 kg/m2 in this case series. A safe procedure with high satisfaction, obese FtM patients should not be excluded from the increased quality of life and dysphoria reduction chest wall masculinization offers.

Breast augmentation in the transgender patient: narrative review of current techniques and complications.

Gender-affirming surgery (GAS) is often a crucial step during the journey to identity actualization for transgender patients. Surgical breast augmentation, or "top surgery", is frequently cited as the most important and sometimes only gender-affirming procedure sought by transfeminine patients. The breast augmentation process is remarkably similar in transgender and cisgender patients. However, there are unique guidelines, anatomic considerations, and contextual issues for the transgender patient population that must be taken into account by providers to achieve optimal outcomes. The aim of this review is to outline the current state of breast augmentation for transfeminine patients. We walk through our suggested pre-surgical evaluation, breast augmentation options, and post-surgical care. In the preoperative period, providers must establish a positive provider-patient relationship that allows for thorough history taking, physical examination, and goal setting. Providers must be able to select an appropriate implant, incision location, and operative plane to balance patient desires and pre-existing anatomic characteristics in transfeminine patients. Postoperatively, the provider must address acute and chronic needs to allow for continued satisfaction and safety. After reading this review, we aim for providers to be well-equipped to provide the highest quality breast augmentation care for their transfeminine patients. As research into best practices for breast augmentation in transfeminine patients continues to develop, we expect that surgical practice will continue to evolve.

ICG Lymphography in a 4-week Postmortem Cadaver: Implications for a Supermicrosurgery Training Model.

Surgical models are invaluable resources for training and for research and innovation. In the field of supermicrosurgery (SM), options for surgical models remain limited and imperfect. We report the use of a fresh, previously frozen 4-week postmortem cadaveric specimen for successful distal to proximal indocyanine green (ICG) lymphography of the upper extremity. Our technique was confirmed with handheld SPY fluorescence imaging, which visualized a clearly defined, linear lymphatic system. By outlining a straightforward, reproducible method of lymphatic mapping in cadaveric specimens, our group aims to expand the frontiers of surgical models for SM.

Cutaneous mucormycosis of the lower extremity leading amputation in two diabetic patients.

Mucormycosis is an invasive, rapidly progressive, life-threatening fungal infection, with a propensity for diabetic, immunosuppressed, and trauma patients. The classic rhinocerebral variation is most common in diabetic patients. While the cutaneous form is usually caused by direct inoculation in immunocompetent patients. Cutaneous mucormycosis manifests in soft tissue and risks involvement of underlying structures. Tibial osteomyelitis can also occur secondary to cutaneous mucormycosis but is rare. Limb salvage is typically successful after lower extremity cutaneous mucormycosis even when the bone is involved. Herein, we report two cases of lower extremity cutaneous mucormycosis in diabetic patients that presented as acute worsening of chronic pretibial ulcers. Despite aggressive antifungal therapy and surgical debridement, both ultimately required amputation. Such aggressive presentation has not been reported in the absence of major penetrating trauma, recent surgery, or burns.

Use of Flap Salvage for Lower Extremity Chronic Wounds Occurs Most Often in Competitive Hospital Markets.

Wounds in the comorbid population require limb salvage to prevent amputation. Extensive health economics literature demonstrates that hospital activities are influenced by level of market concentration. The impact of competition and market concentration on limb salvage remains to be determined. METHODS: Admissions for chronic lower extremity wounds in nonrural hospitals were identified in the 2010-2011 National Inpatient Survey using ICD-9-CM diagnosis codes. The study cohort consisted of admitted patients receiving amputations, salvage without flap techniques (eg, skin grafts), or salvage with flap techniques. The all-service Herfindahl-Hirschman Index (HHI), which is a commonly used tool for market and antitrust analyses, was used to measure hospital competition. Multinomial regression analysis accounting for the complex survey design of the NIS was used to determine the relationship between the HHI and hospital adoption of limb salvage controlling for patient, hospital, and market factors. RESULTS: The study cohort represents 124,836 admissions nationally: 89,880 amputations, 26,715 salvage without flap techniques, and 8241 salvage flap techniques. Diabetics accounted for 64.1% of all study admissions. Hospitals in highly competitive markets performed more flaps for chronic lower extremity wounds than noncompetitive markets. Controlling for other factors, hospitals in highly competitive markets, relative to those in highly concentrated markets, were 2.48 percentage points more likely to perform limb salvage with flaps (P < 0.01). Other factors were less predictive. CONCLUSION: Increased hospital competition is the strongest systems-level predictor of receipt of lower extremity flaps among patients with chronic wounds. Improving access to reconstructive limb services must consider the competitive structure of hospital markets.

Post-Cesarean Section Pyoderma Gangrenosum Presenting with Vasopressor-dependent Shock: Long-term Follow-up after Delayed Primary Closure.

A 28-year-old woman with poor wound healing and surgical site pain presented 5 days post-cesarean section (post-CS) with vasopressor-dependent shock and was eventually diagnosed with postoperative pyoderma gangrenosum (PG). A worsening clinical picture consistent with presumed necrotizing infection necessitated surgical debridement. The patient was ultimately taken to the operating room 4 times with transient improvement after the operations when she received perioperative corticosteroids. We were unable to identify an infectious source and cultures revealed no microorganisms. Dermatopathology revealed neutrophilic infiltrate and focal necrosis without microorganisms. The biopsy site began to concurrently exhibit pathergic changes, leading to a diagnosis of PG. Twelve weeks later, she underwent DPC of her abdominal wound while maintained on an immunosuppressive regimen of cyclosporine and prednisone. Incisional negative pressure wound therapy with a small window was used in the immediate postoperative period to allow for direct visualization of the closed incision. She healed without issue and her immunosuppressive regimen was ultimately discontinued. Postoperative PG is an uncommon diagnosis with high risk of morbidity. It is often mistaken for necrotizing infection. We report a unique case of post-CS PG presenting as vasopressor-dependent shock that was successfully closed with incisional negative pressure wound therapy with a small window.

Free Tissue Transfer for Patients with Chronic Lower Extremity Wounds.

Chronic lower extremity wounds are defined as wounds that fail to heal within 3 months of defect onset. Free tissue transfer offers an opportunity for limb salvage and length preservation. Preoperative optimization includes a medical and nutritional consult, complete work-up by vascular surgery, and an analysis of bony stability and gait biomechanics by podiatric surgery. In the authors' practice, the thigh has proved the workhorse donor site and offers fasciocutaneous and muscle-based flaps depending on defect characteristics. Postoperative care requires early monitoring for flap compromise and continued long-term follow-up for wound recurrence.

Radiation Oncology Applications in Plastic and Reconstructive Surgery: A Nonsystematic Review of Concepts and Principles.

SUMMARY: Careful consideration of radiotherapy can determine the success of reconstructive therapy. There is a broad spectrum of radiotherapy modalities, both benign and malignant. Delivery mechanisms differ in the physical design, setup, radiation source, administrable dosage, and mode of delivery. This range of options allows radiation oncologists to tailor individualized treatment; however, radiotherapy concepts can be challenging for nonspecialists. The purpose of this article is to review general radiation oncology concepts, including essential equipment and radiobiology, and provide plastic surgeons with a basic conceptual understanding to facilitate effective multidisciplinary collaboration with radiation oncologists.

Intraoperative Invasive Blood Pressure Monitoring in Flap-Based Breast Reconstruction: Does It Change Outcomes?

Despite the lack of guidelines regarding the use of intra-arterial lines in postmastectomy breast reconstruction (PMBR), they continue to be used in this setting. In this study of patients undergoing PMBR, we aimed to (1) identify factors associated with intra-arterial line placement, (2) analyze the correlation between intra-arterial monitoring and noninvasive blood pressure (NIBP) monitoring, and (3) investigate whether hemodynamic management differs significantly between patients undergoing intra-arterial blood pressure monitoring versus NIBP. METHODS: All patients undergoing flap-based PMBR between 2017 and 2019 were retrospectively reviewed. Patients were pair-matched based on flap donor site, BMI, and age to identify factors associated with intra-arterial line placement. Methods described by Bland and Altman1 were utilized to determine agreement between intra-arterial line measurements and NIBP. RESULTS: Thirty-two patients were included with 16 patients in the intra-arterial line group and 16 in the NIBP group. None of the factors studied were significantly related to the likelihood of intra-arterial line placement. Agreement analysis demonstrated that mean arterial pressures calculated from intra-arterial line readings were as much as 23 points lower or 12 points higher than those from NIBP. Bias calculations with this extent of difference suggest poor correlation between intra-arterial line readings and NIBP. There was no difference between groups in rate of administration of blood-pressure altering medications (hypertensive: n = 3, 18.8%, P = 1.000; hypotensive: n = 7, 3.8%, P = 1.000). CONCLUSION: Our findings highlight the need for more definitive guidance regarding the use of intra-arterial monitoring in patients undergoing PMBR.