Dual Venous Drainage does not Improve Perforator Flap Performance in Lower Extremity Reconstruction
Shawn Diamond, M.D., Akhil K. Seth, M.D., Anmol S. Chattha, B.A., Qing Z. Ruan, M.D., Mathew L. Iorio, M.D..
Division of Plastic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA.
Routine use of dual venous drainage for all anterolateral thigh flaps has been proposed to decrease flap related complications as compared to single venous anastomosis. We sought to determine if the number of venous anastomosis affected flap complications, specifically in the context of lower extremity perforator flap reconstruction.
Retrospective review of patients who underwent free microvascular tissue transfer with anterolateral thigh flaps – containing at least two perforators within a University referral center and level 1 trauma center from May 2010 to December 2016. All patients operated on after September, 2014 were subject to the same early dangling protocol and physical therapy postoperatively. Patients were divided into groups dependent on whether they received a single venous anastomosis versus two or more venous anastomoses. A univariate analysis determined differences amongst the two groups in terms of demographics and operative details. A multivariate analysis identified independent risk factors associated with patient, donor site, and or flap complications. Subgroup analysis was also performed to determine if flap area, thickness and volume affected flap outcomes based on the number of venous anastomoses.
Forty-four patients met inclusion criteria. Of these, 19 (43.2%) underwent single venous anastomosis while 25 (57.8%) underwent two venous anastomoses. Thinner patients with BMI (26±5 vs 30±6) (p=0.016) and longer elapsed time from injury to reconstruction (724 days vs 387 days) (p=0.045) were more likely to undergo single venous anastomosis. Patients were otherwise evenly matched in 67 other variables compared by univariate analysis. This included average flap area in single versus double venous anastomosis groups: (168cm vs 152cm) (p=0.63) and or flap thickness with (36% vs 44%) (p=0.44) being elevated in a suprascarpal plane. Twenty-six patients were subject to an early dangle protocol in contrast to 18 (41%) who were managed with a prolonged time to limb dependence. The number of venous anastomoses performed did not independently affect flap complication rates for one versus two venous perforators (15.8% v 20%) (p=1). There was one venous thrombosis per group (5.3% vs. 4.0%) (p=1) and no difference in systemic complication rates, specifically deep venous thrombosis. In subgroup analysis, an early dangling protocol, increasing flap area and thickness did not influence rates of either complete or partial flap loss within the single-venous anastomosis group. Return to full weight bearing and ambulation occurred in 88% of all individuals.
The number of venous anastomoses in perforator flaps of the lower extremity did not influence postoperative complications and or soft tissue loss. Increased flap area and thickness along with an early dangling protocol did not compromise single venous flaps. Selecting a single venous outflow vessel can reliably drain perforator flaps for lower extremity reconstructions and routine use of additional anastomosis can be avoided.
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