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Dual Venous Outflow Associated With Improved Outcomes in Lower Extremity Trauma Free Flap Reconstruction
John T. Stranix, MD1, Lavinia Anzai, BS1, Joshua Mirrer, MD1, William Hambley, BS1, Tomer Avraham, MD2, Vishal Thanik, MD1, Pierre B. Saadeh, MD1, Jamie P. Levine, MD1.
1Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY, USA, 2Department of Surgery, Division of Plastic Surgery, Mount Sinai Health System and Icahn School of Medicine, New York, NY, USA.

PURPOSE:
Venous outflow problems are the most common reasons for perioperative flap complications. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction and warrants further investigation.
METHODS:
Retrospective review of our institutional flap registry from 1979 to 2014 identified 464 free flaps performed for lower leg trauma reconstruction. Patient demographics, flap characteristics, and outcomes were examined.
RESULTS:
219 flaps were randomly selected for preliminary analysis. Single-vein outflow was more common (72.6%) than dual-vein (27.3%); majority of recipients were in deep venous system (83.5%) vs. superficial (11.9%) or both (4.6%). Fasciocutaneous flaps were more likely to have two veins than muscle flaps (p=0.002). Complications occurred in 96 flaps (43.8%); with 54 partial flap losses (24.7%), and 11 complete flap losses (5.0%). Dual venous outflow was associated with significant reduction in overall complication rate (RR=0.37, p=0.003). Multivariable regression analysis controlling for age, sex, flap type, flap size, vein size mismatch, and time since injury demonstrated dual-vein outflow to be protective against partial flap failure (RR=0.30, p=0.040) and any flap failure (RR=0.26, p=0.011). No significant difference in operative time was found (p=0.664).
CONCLUSION:
Dual-vein outflow demonstrated 63% reduction in overall complications and 74% reduction in flap failure rate compared to single-vein flaps. These results suggest a protective effect of a dual-vein outflow system, and when considered together with our findings of unchanged operative time, provide evidence for preferential use of two venous anastomoses when possible for free flap reconstruction of lower extremity trauma.


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