The Impact of Increased Body Mass Index on Patient Outcomes and Complications in Microsurgical Lower Extremity Reconstruction.
Elevated body mass index (BMI) is a known perioperative risk factor for complications such as delayed wound healing and infection. However, there is a gap in understanding how elevated BMI impacts outcomes after posttraumatic lower extremity (LE) microvascular reconstruction.
A retrospective review was performed at a level 1 trauma center between 2007 and 2022 of patients who underwent posttraumatic microvascular LE reconstruction. Demographics, flap/wound details, complications, and outcomes were recorded. Patients were stratified into BMI Center for Disease Control categories.
A total of 398 patients were included with an average BMI of 28.2 ± 5.8. Nearly half (45%) of LE defects were located in the distal third of the leg, 27.5% in the middle third, and 34.4% in the proximal third. Most reconstructions utilized muscle-containing flaps (74.4%) compared with fasciocutaneous flaps (16.8%). Surgical approaches included free flaps (47.6%) and local flaps (52.5%). Class III obese patients were significantly more likely to be nonambulatory than nonobese patients (OR: 4.10, 95% CI 1.10-15.2, p = 0.035). At final follow-up, 30.1% of patients with Class III obesity were ambulatory, requiring either wheelchairs (42.3%) or assistance devices (26.9%). There were no significant differences in complication rates based on obesity status (0.704). The average follow-up time for the entire cohort was 5.8 years.
BMI is critical for patient care and surgical decision-making in LE reconstruction. Further research is warranted to optimize outcomes for higher BMI patients, thereby potentially reducing the burden of postoperative complications and enhancing overall patient recovery.
Stanton EW
，Manasyan A
，Boudiab E
，Carey JN
，Daar DA
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Larger free flap size is associated with increased complications in lower extremity trauma reconstruction.
Free flap reconstruction after lower extremity trauma remains challenging with various factors affecting overall success. Increasing defect and flap size have been demonstrated to be a surrogate for overall injury severity and correlated with complications. In addition, larger free flaps that encompass more tissue theoretically possess high metabolic demand, and may be more susceptible to ischemic insult. Therefore, the purpose of our study was to determine how flap size affects microsurgical outcomes in the setting of lower extremity trauma reconstruction.
Retrospective review of 806 lower extremity free flap reconstructions performed from 1979 to 2016 among three affiliated hospitals: a private university hospital, Veterans Health Administration Hospital (VA), and a large, public hospital serving as a level 1 trauma center for the city. Soft tissue free flaps used for below the knee reconstructions of traumatic injuries were included. A receiver operating curve (ROC) was generated and Youden index was used to determine the optimal flap size for predicting flap success. Based on this, flaps were divided into those smaller than 250 cm2 and larger than 250 cm2 . Partial flap failure, total flap failure, takebacks, and overall major complications (defined as events involving flap compromise) were compared between these two groups. Multivariate logistic regression was performed to determine whether flap size independently predicts complications and flap failures, controlling for injury-related and operative factors.
A total of 393 patients underwent lower extremity free tissue transfer. There were 229 flaps (58.2%) with size <250 cm2 and 164 flaps (41.7%) ≥ 250 cm2 . ROC analysis and Youden index calculation demonstrated 250 cm2 (AUC 0.651) to be the cutoff free flap for predicting increasing flap failure. Compared to flaps with less than 250 cm2 , larger flaps were associated with increased major complications (33.6% vs. 50.0%, p = .001), any flap failure (11.8% vs. 25.0%, p = .001) and partial flap failure (4.8% vs. 14.6%, p = .001). Logistic regression analysis controlling for age, flap type, era of reconstruction, number of venous anastomoses, presence of associated injuries, presence of a bone gap, vessel runoff, and flap size identified increasing flap size to be independently predictive of major complications (p = .05), any flap failure (p = .001), partial flap failure (p < .001), and takebacks (p = .03). Subset analysis by flap type demonstrated that when flap size exceeded 250 cm2 , use of muscle flaps was associated with significantly increased flap failure rates (p = .008) while for smaller flap size, there was no significant difference in complications between muscle and fasciocutaneous flaps.
Increasing flap size is independently predictive of flap complications. In particular, a flap size cutoff value of 250 cm2 was associated with significantly increased flap failure and complications particularly among muscle-based flaps. Therefore, we suggest that fasciocutaneous flaps be utilized for injuries requiring large surface area of soft tissue reconstruction.
Lee ZH
，Abdou SA
，Ramly EP
，Daar DA
，Stranix JT
，Anzai L
，Saadeh PB
，Levine JP
，Thanik VD
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A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction.
Complex lower extremity wounds present a significant challenge to the reconstructive surgeon. We report a consecutive experience of free tissue transfers for lower extremity reconstruction with a focus on outcomes and flap selection.
A retrospective review of all free tissue transfers for lower extremity reconstruction between 2006 and 2011 was performed. Minor complications were defined as nonoperative complications (infection, seroma, hematoma, wound breakdown, and partial loss). Major complication required a surgical intervention (total flap loss, thrombosis, nonunion, amputation, and hematoma).
A total of 119 free flaps were performed in 114 patients. Reconstructed defects were most commonly derived from acute traumatic (N = 40) or chronic traumatic (N = 34) wounds, oncologic (N = 14), or diabetic (N = 8). Flap loss occurred at a rate of 5.9% and the overall lower extremity salvage rate was 93%. Complications were significantly higher for free tissue transfers to the region of the distal tibia (p = 0.04). Major complications were significantly higher in patients with chronic obstructive pulmonary disease (p = 0.02) and in patients who experienced intraoperative technical difficulties (p = 0.014). Flap loss was significantly higher when the rectus abdominis flap was used (p = 0.02) and when a delayed venous thrombotic event occurred (p = 0.001).
Patient comorbidities and defect location can be associated with higher rates of complications; flap selection and delayed venous thrombotic events appear to be associated with flap failure.Level of Evidence Prognostic/risk category, level III.
Fischer JP
，Wink JD
，Nelson JA
，Cleveland E
，Grover R
，Wu LC
，Levin LS
，Kovach SJ
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