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Should the Microsurgery Pendulum Swing from Fasciocutaneous to Muscle Free Flaps in Peripheral Vascular Disease Patients? An Analysis of Outcomes in the Comorbid Limb Salvage Population
Adaah A. Sayyed1,2, Romina Deldar1, ZoŽ K. Haffner1,2, John D. Bovill2, Brian Truong2, Nisha Gupta2, Christopher E. Attinger1, Cameron M. Akbari1, Karen K. Evans1
1MedStar Georgetown University Hospital, Washington, DC; 2Georgetown University School of Medicine, Washington, DC

Objective: Free tissue transfer (FTT) is critical in complex lower extremity (LE) limb salvage to prevent progression to amputation. Common FTT flap compositions include (1) fasciocutaneous, which comprise skin, subcutaneous tissue, and fascia, and (2) muscle, which comprise vascularized muscle without skin. It is theorized that use of fasciocutaneous flaps may compromise wound healing in the setting of peripheral vascular disease (PVD), due to reduced arterial runoff and high resistance at the skin capillary level. Comparatively, muscle flaps confer a low resistance, high outflow system that may be more amenable to healing in PVD patients. We evaluate surgical outcomes following fasciocutaneous versus muscle LE FTT among PVD patients.
Methods: A single institution retrospective review identified PVD patients who underwent FTT between 2011 and 2021. All angiograms and vascular interventions were performed by a single vascular surgeon and all FTT by the senior author. Patients were divided into fasciocutaneous and muscle flap groups. Primary outcomes included postoperative complications, flap success, post-reconstruction vascular interventions, limb salvage, and ambulatory status.
Results: 212 patients underwent LE FTT, of which 113 had PVD based on preoperative arteriogram. Of these patients, 60.2% received fasciocutaneous flaps (n=68) and 39.8% received muscle flaps (n=45). Mean age and BMI were 60.3 years and 29.0kg/m2, respectively. Forty-two patients (37.2%) underwent preoperative endovascular interventions. Flap success rate was 98.2% (n=111). Overall complication rate was 41.2% following fasciocutaneous flaps compared to 24.4% following muscle flaps (p=0.067). Fasciocutaneous flap patients had higher odds of ulceration requiring repeat angiogram within one year of reconstruction compared to muscle flap patients (p=0.039; OR 5.1, [1.1-23.7]), and higher odds of requiring repeat angiogram overall (p=0.039; OR 3.4 [1.1-10.9]). The proportion of patients requiring revascularization procedures in the operated limb within one year of surgery were similar in both groups (p=0.155). At mean follow-up 20.6+19.7 months, overall limb salvage and ambulatory rates were 87.6% and 89.4%, respectively, with a mortality rate of 8.9%.
Conclusion: This is the first study comparing revascularization rates among PVD patients undergoing fasciocutaneous versus muscle flap reconstruction for LE wounds. Fasciocutaneous flaps demonstrated a higher need for repeat arteriogram following reconstruction due to limb ulceration and trended towards higher postoperative complication rates, possibly due to the increased resistance in fasciocutaneous flaps. These findings suggest consideration of muscle flaps as the first choice for FTT in PVD patients, however larger, multi-institutional studies are needed to further evaluate outcomes of flap composition choice in PVD patients.


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