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Purpose: Although blood loss in microsurgical reconstruction is rarely large enough to be life-threatening, preoperative anemia can be a particular issue in terms of postoperative morbidity, impaired wound healing, and compromised tissue viability. We seek to review the effect of preoperative hemoglobin (Hgb) levels on perioperative blood transfusion (PBT) requirements and complications to guide management of patients with preexisting anemia undergoing reconstruction., Methods: PubMed, Embase, and Scopus were queried for relevant articles. Inclusion criteria were as follows: original studies investigating outcomes and PBT requirements in flap-based reconstruction based on preoperative Hgb levels. Patient and study characteristics were analyzed using descriptive statistics. A meta-analysis was conducted to assess transfusion requirements across the included studies using Stata (version 18.0 Stata Corp, College Station, Texas, USA). The Fisher method was used to aggregate individual study p values into a single combined value to statistically assess the combined findings, where a p value of < 0.05 was set as statistically significant., Results: One thousand three hundred and eighty-nine studies were screened for title and abstract relevance, 14 of which met the inclusion criteria, including a total of 61,116 patients. Meta-analysis of the studies revealed a PBT requirement of 36.2% for anemic individuals, significantly higher than the 20.0% for those with normal preoperative Hgb levels (p < 0.001), with an average 4.9 versus 2.4 units of packed red blood cells being transfused (p < 0.001). The majority of studies concluded that preoperative anemia was associated with medical complications, such as myocardial infarction, stroke, and infection (p < 0.001). While six studies reported a significant relationship between low preoperative Hgb and flap morbidity (flap loss and partial flap necrosis), two studies found no correlation. The overall postoperative complication rate across the studies was 42.2% among patients with low preoperative Hgb levels, whereas the nonanemic group demonstrated a markedly lower rate of 13.9% (p < 0.001)., Conclusion: The existing evidence is strongly suggestive of increased PBT requirement in patients with anemia, highlighting the necessity for preoperative optimization of Hgb levels and intraoperative monitoring. While preliminary evidence demonstrates a relationship between anemia and medical complications, more research is warranted to characterize the specific association between preoperative Hgb levels and flap morbidity., (© 2024 Wiley Periodicals LLC.)

Introduction: Lower extremity (LE) reconstruction in the elderly population presents a multifaceted challenge, primarily due to age-related degenerative changes, comorbidities, and functional decline. Elderly individuals often encounter conditions such as osteoarthritis, osteoporosis, and cardiovascular and peripheral artery disease (PAD), which can severely compromise the structural integrity and function of the lower limbs. As such, we aim to assess postoperative complications and functional recovery following LE reconstruction in elderly patients., Methods: Patients ≥ 18 years who underwent post-traumatic LE reconstruction with flap reconstruction at a Level 1 trauma center between 2007 and 2022 were included. Patient demographics, flap/wound characteristics, complications, and ambulation for the elderly (≥ 60 years old) and the control (< 60 years old) cohorts were recorded. The primary outcome was final ambulation status, modeled with logistic regression. Secondary outcomes included postoperative complications., Results: The mean ages of the control (n = 374) and elderly (n = 49) groups were 37.4 ± 12.6 and 65.8 ± 5.1 years, respectively. Elderly patients more frequently required amputation after flap surgery (p = 0.002). There was no significant difference between the two cohorts in preoperative ambulation status (p = 0.053). Postoperatively, 22.4% of elderly patients were independently ambulatory at final follow-up, compared to 49.5% of patients < 60. Of the elderly, 14.3% could ambulate with an assistance device (cane, walker, etc.), compared to 26.5% in the control group. A wheelchair was required for 46.9% of elderly patients, significantly higher than the 22.7% of those < 60 years of age (p < 0.001). Multivariate regression confirmed an association between older age and nonambulatory final status (p = 0.033)., Conclusion: LE reconstruction can likely be performed safely in patients 60 years of age or older. However, older age is independently associated with significantly worse postoperative ambulation. Preoperative assessment, including gait and muscle strength, and early initiation of postoperative rehabilitation can potentially improve ambulation in elderly individuals undergoing LE reconstruction., (© 2024 Wiley Periodicals LLC.)

Background: 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., Methods: 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., Results: 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., Conclusions: 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., (© 2024 Wiley Periodicals LLC.)

Purpose: The superficial temporal artery (STA) and facial artery (FA) are two commonly used recipient vessels when performing free tissue transfer to the head and neck. This meta-analysis compares the impact of recipient vessel location on free flap outcomes in scalp reconstruction., Methods: A systematic review was conducted following PRISMA-P guidelines using six databases. Studies reporting free tissue transfer using the STA or FA as a recipient vessel for reconstructing scalp defects were included. Outcomes of interest included flap loss, partial flap necrosis, wound dehiscence, venous thrombosis, and infection rates. Quality evaluation was performed using ASPS criteria and the ROBINS-I tool., Results: Of 3270 identified articles, 12 were included for final analysis. In total, 125 free flaps were identified (75 STA, 50 FA). Pooled analysis demonstrated an overall flap survival rate of 98.4% (STA 98.7% vs. FA 98.0%; p = .782). The mean defect size was significantly greater for flaps using the STA compared with the FA (223.7 ± 119.4 cm 2 vs. 157.1 ± 96.5 cm 2 , p = .001). The FA group had a higher incidence of wound dehiscence than the STA group (14.0% vs. 1.3%, p = .005). However, meta-analysis demonstrated no significant difference in rates of wound dehiscence, flap loss, partial flap necrosis, venous congestion, or postoperative infection between groups., Conclusion: This is the first systematic review and meta-analysis to assess recipient vessel selection in scalp reconstruction. Our results do not support a single vessel as the superior choice in scalp reconstruction. Rather, these findings suggest that the decision between using the STA or FA is multifaceted, requiring a flexible approach that considers the individual characteristics of each case. Further research is needed to explore additional factors influencing recipient vessel selection, including defect location, radiation therapy, and prior head and neck surgery., (© 2024 Wiley Periodicals LLC.)

Introduction: Reducing donor site morbidity after deep inferior epigastric artery perforator (DIEP) flap harvest relies mainly upon maintaining integrity of the anterior rectus sheath fascia. The purpose of this study is to describe our minimally-invasive technique for robotic DIEP flap harvest., Methods: A retrospective review of four patients undergoing seven robotic-assisted DIEP flaps from 2019 to 2020 was conducted. Average patient age and BMI were 52 years (range: 45-60 years) and 26.7 kg/m 2 (range: 20.6-32.4 kg/m 2 ), respectively. Average follow-up was 6.31 months (range: 5.73-7.27 months). Robotic flap harvest was performed with intramuscular perforator dissection in standard fashion, followed by the transabdominal preperitoneal (TAPP) approach to DIEP pedicle harvest using the da Vinci Xi robot. Data was collected on demographic information, perioperative characteristics. Primary outcomes included successful flap harvest as well as donor site morbidity (e.g., abdominal bulge, hernia, bowel obstruction, etc.)., Results: All four patients underwent bilateral abdominally-based free flap reconstruction. Three patients received bilateral robotic DIEP flaps, and one patient underwent unilateral robotic DIEP flap reconstruction. The da Vinci Xi robot was used in all cases. Average flap weight and pedicle length were 522 g (range: 110-809 g) and 11.2 cm (range: 10-12 cm), respectively. There were no flap failures, and no patient experienced abdominal wall donor site morbidity on physical exam., Conclusion: While further studies are needed to validate its use, this report represents the largest series of robotic DIEP flap harvests to date and is a valuable addition to the literature., (© 2022 Wiley Periodicals LLC.)

Background: 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., Methods: 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 cm 2 and larger than 250 cm 2 . 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., Results: A total of 393 patients underwent lower extremity free tissue transfer. There were 229 flaps (58.2%) with size <250 cm 2 and 164 flaps (41.7%) ≥ 250 cm 2 . ROC analysis and Youden index calculation demonstrated 250 cm 2 (AUC 0.651) to be the cutoff free flap for predicting increasing flap failure. Compared to flaps with less than 250 cm 2 , 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 cm 2 , 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., Conclusion: Increasing flap size is independently predictive of flap complications. In particular, a flap size cutoff value of 250 cm 2 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., (© 2020 Wiley Periodicals, Inc.)

Purpose: There is a dearth of literature dedicated to specifically evaluating the use of free flap reconstruction in pediatric lower extremity traumas. This study aims to identify specific risk factors for flap failure in pediatric lower extremity trauma reconstruction., Methods: Retrospective review of 53 free flaps in our lower extremity database (1979-2017) identified all free flaps performed for traumatic reconstruction in children <18 years of age at our institution., Results: Fifty-three free flaps (11.1%) were performed in 49 pediatric patients. The majority of patients were male (69.8%). Arterial injury was present in 19 patients (35.8%) and was associated with significantly higher flap failure rates compared to patients without arterial injury (36.8% vs 8.8%, P = 0.020) with RR = 6.0. This was again found to be true on multivariable logistic regression controlling for age, sex, flap type, and degree of arterial or venous mismatch (RR = 53, P = 0.016). Analysis of anastomotic vessel sizes revealed significantly increased risk of flap failure with increasing degree of arterial size mismatch on logistic regression (RR = 6.1, p = .02). Similar analysis for venous data was performed and revealed trending towards similar findings without reaching statistical significance (P = .086); however, the presence of any venous size mismatch was associated with significantly increased risk of flap failure on χ 2 analysis (P = 0.041)., Conclusion: Free flap reconstruction in the pediatric trauma population is safe with similar survival outcomes when compared to the adult population. Arterial injury and vessel size mismatch were associated with significantly higher flap failure rates in this population., Level of Evidence: Level III., (© 2019 Wiley Periodicals, Inc.)