American Association of Plastic Surgeons

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Proximal Versus Distal Recipient Vessels in Traumatic Lower Extremity Microvascular Reconstruction: A 37-Year Retrospective Series
William J. Rifkin, BA, John T. Stranix, MD, Zachary M. Borab, MD, Adam Jacoby, MD, Z-Hye Lee, MD, Lavinia Anzai, MD, Daniel J. Ceradini, MD, Vishal Thanik, MD, Pierre B. Saadeh, MD, Jamie P. Levine, MD.
Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA.

PURPOSE: Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. This study investigates the impact of lower extremity recipient vessel location on free flap outcomes.
METHODS: Retrospective review from 1979-2016 identified 806 lower extremity free flaps; 312 soft tissue free flaps for open tibia fracture coverage met inclusion criteria. Patient demographics, flap characteristics, and outcomes were examined. Analysis was performed using Chi-square and binary logistic regression.
RESULTS: Most anastomoses, 252 (80.7%), were performed proximal to the zone of injury, while 60 (19.3%) anastomoses were performed distally. Distal anastomoses were not associated with increased rates of total flap failure (9.3%, 5/54 vs. 9.3%, 21/226; p=0.815) or partial flap failure (7.4%, 4/54 vs. 11.9%, 27/226; p=0.978) compared to proximal anastomoses when controlling for confounding variables, such as presence of arterial injury, flap type, and time from injury to coverage. Furthermore, distal anastomoses were not associated with increased rates of operative take backs (19.6%, 10/55) compared to proximal anastomoses (23.8%, 51/214; p=0.356).
CONCLUSION: There was no statistically significant difference in complication or flap failure rates for anastomoses performed proximal or distal to the zone of injury. These findings suggest that as long as the recipient vessels are outside the zone of injury, selection should be based on pedicle length, ease of vessel exposure, and adequate inflow/outflow rather than simply a proximal or distal orientation relative to the injury.


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