Plastic Surgery Research Council

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Comparison of Outcomes Between Muscle and Fasciocutaneous Free Flaps in Foot and Ankle Reconstruction
Z-Hye Lee, MD1, Salma Abdou BA1, David Daar MD, MBA1, Lavinia Anzai, MD1, John T. Stranix MD1, Vishal Thanik MD1, Jamie P. Levine MD1, Pierre B. Saadeh MD1
Hansjörg Wyss Department of Plastic Surgery New York University School of Medicine

PURPOSE:
The distal lower extremity poses unique reconstructive challenges due to its requirements for durability of the loadbearing plantar surface and for thin, pliable contour in the dorsal foot and ankle region. The purpose of this study is to compare outcomes between muscle and fasciocutaneous flaps in patients undergoing free tissue transfer for foot and ankle wounds.
METHODS:
A retrospective review of 806 lower extremity free flap reconstructions (1979-2016) was performed. Soft tissue free flaps used for traumatic injuries of the foot and ankle met inclusion criteria. Endpoints included takebacks, partial flap failure, total flap failure and wound complications. Defects were classified as those primarily involving the non-weightbearing surface (dorsal foot, ankle) vs. weight-bearing surface (plantar).
RESULTS: 165 cases utilizing 14 different flaps (latissimus = 40, rectus abdominis = 33, parascapular = 26, gracilis = 19, serratus = 12, ALT = 12, other = 23) were identified. Muscle flaps (n=110) predominated compared to fasciocutaneous flaps (n=55). Defects involving the non-weight bearing surface were more common (n=86) compared to those involving the weight-bearing surface (n=79). There was no significant difference in use of muscle vs. fasciocutaneous flaps by defect type (p=0.270). In addition, presence of arterial injury (p=0.745), use of end-to-end arterial anastomosis (p=0.333) and number of venous anastomoses (p=0.159) did not differ between muscle vs. fasciocutaneous flaps. The mean follow-up time was 36.4 months (range 0.1 to 165.4 months). Complications occurred in 56 flaps (33.9%): 21 takebacks (12.7%), 11 partial losses (6.7%), 6 complete losses (3.6%), 25 wound breakdowns (15.2%). There were no differences in takebacks, partial flap failure or total flap failure. However, fasciocutaneous flaps had fewer wound complications compared to muscle flaps (7.3% vs. 19.1%, p=0.046). Subgroup analysis for muscle flaps demonstrated lower rates of partial flap failure (p=0.045) and trend towards decreased wound complication rates (p=0.097) in flaps with dual venous outflow. In addition, the latissimus flap was associated with higher partial flap failure (p=0.009) and wound complication rates (p=0.040) compared to the other muscle flaps.
CONCLUSION:
Compared to fasciocutaneous flaps, muscle flaps demonstrated higher rates of wound complications. While flap selection in foot and ankle reconstruction should remain individualized depending on the nature of the defect, our results support the use of fasciocutaneous over muscle flaps in this region.


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