Scientific Abstract Presentations: Reconstructive Session 3 Thursday, September 26 Thu, Sep 26 5:00-6:00 p.m. PDT

Background: The pedicled sartorius muscle flap is recognized for its utility in reconstructing complex groin wounds due to its proximity to the groin, relatively straightforward dissection, and minimal to no functional loss. However, there is no comprehensive understanding of how comorbidities and laboratory values, including hemoglobin (Hgb), albumin, and C-reactive protein (CRP), influence complication rates. This understanding is crucial, as complications may compromise vascular repairs and grafts, potentially endangering limb viability. Thus, this study explores the relationship between such factors and postoperative complications.

Methods: A retrospective cohort analysis was conducted on patients who underwent sartorius flap procedures for groin wounds from 2014 to 2020. At our institution, the sartorius muscle flap is used primarily when assisting vascular surgery with complex groin reconstruction after various bypass operations, including redo procedures. Data collected include patient demographics, existing comorbidities, laboratory values, and postoperative complications. Data were summarized as means ± standard deviations, and univariate analyses using odds ratios (OR) and 95% confidence intervals (CI) evaluated the impact of variables on postoperative outcomes. P-values<0.05 were considered statistically significant.

Results: Of the 425 cases included, the mean age was 66.3 ± 12.5 years, with a distribution of 61.2% males and 38.8% females. Body mass index (BMI) was 26.4 ± 6.3. Clinical characteristics showed a mean creatinine level of 1.2 ± 1.0 mg/dL, Hgb of 11.2 ± 2.1 g/dL, albumin of 2.9 ± 0.8 g/dL, and CRP of 95.6 ± 87.4 mg/L. 70.8% had hypertension, 80.2% had peripheral vascular disease (PVD), and 35.5% had coronary artery disease (CAD). 11.1% had insulin-dependent diabetes mellitus (IDDM) and 21.6% had non-insulin-dependent diabetes mellitus (NIDDM). In 42.1% of the cases, incisional wound vacuum-assisted closure was utilized, prophylactic antibiotics were administered in 31.3%, and drain placement was employed in 91.5%.

145 (34.1%) patients had a postoperative complication. Having IDDM (OR=0.50, CI=0.27-0.93, p=0.028) or higher BMI (OR=0.94, CI=0.91-0.97, p<0.001) was clinically associated with a reduced risk of complications. Prophylactic antibiotics use significantly lowered complication risk (OR=0.58, CI=0.38-0.88, p=0.011). Further, rising hemoglobin levels were correlated with increased complication rates (OR=1.12, CI=1.01-1.23, p=0.026). There was no statistically significant impact with regards to patient albumin (OR=0.89, CI=0.35-2.26, p=0.810), CRP (OR=1.00, CI=1.00-1.00, p=0.861), or creatinine (OR=0.85, CI=0.70-1.03, p=0.089). Other variables, including gender, hypertension, hyperlipidemia, tobacco use, PVD, COPD, CAD, and additional laboratory markers, did not demonstrate a statistically significant correlation with complications.

Conclusion: The study elucidates the complex relationship between comorbidities, laboratory values, and postoperative complications in patients undergoing sartorius flap reconstruction. Unexpectedly, IDDM and a higher BMI were protective against post-operative complications, which may be related to higher vigilance on the part of the providers in caring for these complex patients. As clinically expected, prophylactic antibiotics decreased complications; however, higher hemoglobin was associated with higher complication risk. This is of unclear clinical significance. When evaluating these patients, caution should be taken when assessing comorbidities, which are often numerous in complex vascular surgery patients undergoing bypass procedures. These findings encourage further research into developing refined risk assessment models to enhance surgical success and patient recovery.

Purpose: There is a disproportionate burden of patients requiring microsurgical reconstruction in low- and middle-income countries (1). Despite this, there are few plastic surgery departments which have demonstrated the capacity to perform free flap procedures in rural African contexts (2). The purpose of this study was to investigate the feasibility of a surgeon certified by the American Board of Plastic Surgery establishing a microsurgical practice at a resource limited, non-governmental hospital in rural western Kenyan.

Methods: We performed a retrospective review on all patients who received a free flap procedure by a single surgeon at one institution from November 2022 to November 2023. Information was retrieved relating to age, sex, medical history, wound etiology, flap performed, peri- and post-operative complications and length of stay.

Results: Nineteen free flaps were perfumed on 17 patients (13 male). Average age of patient was 39 ± 18.5. Most common indications were lower extremity soft tissue defects (10) and facial reconstructions for orofacial gangrene (4) and neoplasms (2). The most common flap performed was anterolateral thigh (n=11). All procedures were performed under surgical microscope. 13 patients (76.4%) experienced a post-operative complication. Overall flap survival rate was 94.7% percent.

Conclusions: Despite high rates of complications, microsurgical practices can be safely established in limited-resource African settings with flap survival rates that are similar to those reported in many western settings. Given the burden of patients necessitating microsurgical reconstruction in LMICs, expanding efforts to partner in training and providing resources to plastic surgeons working in LMICs is warranted (4).

1. Nangole WF, Khainga S, Aswani J, Kahoro L, Vilembwa A. Free Flaps in a Resource Constrained Environment: A Five-Year Experience-Outcomes and Lessons Learned. Plastic Surgery International. 2015;2015:1-6. doi:10.1155/2015/194174
2. Citron I, Galiwango G, Hodges A. Challenges in global microsurgery: A six year review of outcomes at an East African hospital. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2016;69(2):189-195. doi:10.1016/j.bjps.2015.10.016
3. Mofikoya BO, Belie O, Ugburo AO, Ajani AO. Clinical outcome of microsurgical free flap procedures in Lagos, Nigeria. Nigerian Journal of Plastic Surgery. 2020;16(2):45
4. Banda CH, Georgios P, Narushima M, Ishiura R, Fujita M, Goran J. Challenges in global reconstructive microsurgery: The sub-Saharan african surgeons' perspective. JPRAS Open. 2019;20:19-26. doi:10.1016/j.jpra.2019.01.009

BACKGROUND: After free tissue transfer, the most critical period with the highest risk of flap failure is within the first 72 hours (1). Most takebacks demonstrate signs of vascular compromise within these first 72 hours (2), and the majority of thrombi present within the first two postoperative days. The atraumatic, highly comorbid, chronic wound patient population who undergo lower extremity free tissue transfer have multiple thrombogenic factors that may contribute to higher rates of takeback. Thus, this study aims to identify any perioperative risk factors that contribute to rates of takeback. METHODS: A retrospective review of patients that underwent lower extremity free tissue transfer (FTT) at a single-center academic institution between the years of 2011 and 2023 were included in this study. Patient medical comorbidities, history of immunosuppression, surgical details, postoperative complications, and overall outcomes data were collected. Rates takeback to the operating room for any complication was recorded between and further characterized by timing and reason for takeback. Statistical univariate analyses were performed to evaluate any significant associations between the rates of FTT takeback and patient-related or surgical factors. RESULTS: A total of 300 patients with LE FTT were reviewed. Takeback rate was 6% (n=18), which occurred at a median of 18.6 hours (IQR:20.86) from end of FTT procedure. Overall flap salvage rate was 72.7% (n=8/11). From post-FTT to takeback of zero to 12 hours, the flap salvage rate was 100% (n=2/2). From 12 to 24 hours, the flap salvage rate was 66.7% (n=4/6) and from 24 to 72 hours, the flap salvage rate was also 66.7% (n=2/3). Common reasons for takeback were venous thrombosis requiring anastomotic revision. Of the patients who had takebacks, their average CCI was 3.9 (SD:2.3). On univariate analysis, the two venous anastomoses was independently associated with lower rates of takeback (OR=0.11, CI=0.03-0.41). Chronic steroid use (OR=8.7, CI=2.0-36.8) were significantly associated with higher rates of takeback. On multiple logistic regression, chronic steroid use (OR:10.8, CI=2.14-54.7) remained as a predictive risk factor for rates of takeback while two venous anastomoses remained independently predictive of lower rates of takeback (OR=0.10, CI=0.03-0.39). CONCLUSION: Vascular compromise leading to an emergent procedure in LE FTT remains a greatly feared complication, especially in a highly comorbid population. In our study, the greater number of venous anastomoses predicted lower odds of takeback. Careful postoperative monitoring, timely intervention, and two venous anastomoses should be considered when technically possible to maximize chances of outflow, especially in this highly comorbid and vasculopathic population. REFERENCES: 1. Bigdeli AK, Gazyakan E, Schmidt VJ, Bauer C, Germann G, Radu CA, Kneser U, Hirche C. Long-Term Outcome after Successful Lower Extremity Free Flap Salvage. J Reconstr Microsurg. 2019 May;35(4):263-269. doi: 10.1055/s-0038-1675146. Epub 2018 Oct 16. PMID: 30326522. 2. Chen KT, Mardini S, Chuang DC, Lin CH, Cheng MH, Lin YT, Huang WC, Tsao CK, Wei FC. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg. 2007 Jul;120(1):187-195. doi: 10.1097/01.prs.0000264077.07779.50. PMID: 17572562.

PURPOSE Autologous breast reconstruction using Deep Inferior Epigastric Perforator (DIEP) flaps has been successfully performed in patients across all BMI categories. However, higher rates of adverse outcomes, such as wound complications and flap failure, have been reported in patients with elevated BMIs. This study aims to utilize the TriNetX research network database to investigate outcomes in patients undergoing DIEP flap autologous breast reconstruction, focusing on the impact of different BMIs and exploring alternative nutritional markers beyond BMI.

METHODS Our retrospective analysis involved screening de-identified patient records spanning 20 years, encompassing data from 107,714,666 patients and 62 healthcare organizations across the US. Patients who underwent DIEP flaps were identified by CPT code and stratified into two BMI cohorts: 18.5-34.9 (n=837) and 35+ (n=4,328). Patients with BMI over 35 were further categorized by degree of diabetic control based on their most recent Hga1c values: 7% and under (controlled) or 7.01% or more (uncontrolled). Cohorts were propensity-matched for age, race, ethnicity, smoking status, diabetes, and history of irradiation prior to comparing 90-day measures of association outcomes defined by ICD-10 codes.

RESULTS Patients with a BMI of 35+ had significantly higher rates of infection (RR 1.632, p=0.0021) and dehiscence (RR 1.708, p=0.0001) compared to those with a BMI of 18.5-34.9. No significant differences were observed in rates of seroma, hematoma, or revision between the two BMI cohorts. In the subgroup analysis of patients with a BMI of 35+ based on diabetes control, uncontrolled patients had a significantly higher rate of operative hematoma or seroma and revision of the reconstructed breast compared to controlled patients (p=0.0003). Low albumin levels were associated with higher revision rates (p=0.0009).

CONCLUSION Beyond BMI, considering a broader range of nutritional markers can enhance preoperative assessments and interventions to improve outcomes in autologous breast reconstruction. The significance of uncontrolled diabetes underscores the importance of evaluating glycemic control in predicting adverse outcomes. Despite higher BMIs, patients may still exhibit low albumin levels that predispose patients to additional complications and wound healing issues, occasionally needing operative intervention beyond standard care. Additionally, utilizing a large federated database enables a thorough analysis across diverse patient profiles, overcoming limitations inherent in single-center studies.

Background: In the United States, 2.4 to 4.5 million individuals suffer from chronic lower extremity (LE) wounds, with a rising incidence due to an aging population, diabetes mellitus (DM), peripheral vascular disease (PVD), and obesity. The fillet flap (FF) leverages the "spare parts" algorithm in reconstructive surgery–utilizing tissue from amputated or otherwise non-salvageable body parts, avoiding donor-site morbidity. However, its efficacy for minor LE amputations due to chronic LE wounds remains understudied. This study aims describes our institutional experience with FF in high-risk patients with chronic LE wounds.

Methods: A retrospective review of patients undergoing foot amputation with FF coverage for chronic LE wounds between January 2013 to August 2023 was conducted. Patient characteristics, operative details, and postoperative outcomes were collected. Primary outcome was FF survival, defined as no necrosis ≤7 days postoperatively. Secondary outcome was complications, categorized into short- (<30 days postoperatively) and long-term (≥30 days postoperatively).

Results: A total of 70 patients were included for analysis. Mean age and body mass index (BMI) were 65.0+13.7 years and 28.8±6.4 kg/m2, respectively. In 45 patients (64.2%) with preoperative angiography, patency rates were: first dorsal metatarsal (n=10, 22.2%), lateral plantar (n=7, 15.6%), medial plantar (n=6, 13.3%), and dorsalis pedis (n=4, 8.9%) arteries. Mean follow-up duration was 9 (IQR: 32) months. Fourteen (20.0%) patients experienced short-term complications, including re-ulceration (n=7, 10.0%), deep surgical site infection (SSI; i.e., abscess, gangrenous necrosis; n=6, 8.6%), and superficial SSI (i.e., cellulitis, n=4, 5.7%). Eleven (15.7%) patients necessitated reoperation for debridement (n=4, 5.7%), wound closure (n=4, 5.7%), flap necrosis (n=3, 4.29%), incision and drainage (ID; n=1, 1.4%), and/or split-thickness skin grafting (STSG; n=1, 1.4%), foreign body exploration (n=1, 1.4%). Twenty-eight (40.0%) patients experienced long-term complications, including re-ulceration (n=21, 28.6%), deep SSI (n=16; 22.9%), and superficial SSI (n=5, 7.1%), and hematoma formation (n=1, 1.4%). Thirty-two (52.89%) patients necessitated re-operation for debridement (n=16, 22.9%), ID (n=8, 11.4%), STSG (n=6, 8.6%), wound closure (n=5, 7.1%), hematoma evacuation (n=1, 1.4%), and/or removal of heterotopic bone (n=1, 1.4%). Collectively, FF survival was 90% (n=63).

Conclusion: FF facilitates reconstruction in complex cases, and should be integrated into each chronic LE wound algorithm to avoid additional donor-site morbidity and facilitate stump-length preservation or limb salvage.

Purpose: Venous thromboembolism (VTE) is well-documented post operative complication with potentially life-threatening sequelae.[1] While the risk of VTE in plastic surgery patients is low, these devastating consequences pose a critical need for assessment of risk factors.[2] Recent research has elucidated that a history of COVID-19 infection may be an additional predisposing risk factor to VTE formation. [3,4] Therefore our study aims to assess the risk of VTE in panniculectomy patients with the history of COVID-19.

Methods: The TriNetX LLC. National Health Research database was queried to identify patients who underwent panniculectomy in the years 2017-2020 (pre-pandemic) and 2020-2023 (post-pandemic). In addition, post-pandemic patients were further studied by querying the data to look for those with a history of COVID versus those without. These cohorts were analyzed to calculate the incidence rate of VTE in the 30 days post operative period.

Results: A total cohort of 7,114 patients who underwent panniculectomy on prophylactic anticoagulation were identified. There were 3,015 patients in the pre-pandemic and 4,099 patients in the post-pandemic group. In the post-pandemic group, there were 790 patients with a prior history of COVID and 3,309 patients without. The rate of VTE was not significantly different in the pre (3.2%) versus post (3.0%) pandemic cohorts (p=0.64). However, in the post-pandemic cohort, there was a significant difference in VTE rates between patients with (4.9%) and without (2.5%) prior history of COVID (p= 0.0002).

Conclusion: Our study showed there was no significant increase in VTE incidence after panniculectomy during the pandemic. However, patients with a history of COVID may be more susceptible to postoperative VTEs as its true long term morbid effects are yet to be fully understood. Therefore, history of COVID should be carefully considered when determining a patient's VTE risk and warrants further study for optimal perioperative and postoperative anticoagulation strategies.

References: 1. Young, V., Watson, M., 2006. Continuing medical education article-patient safety: The need for venous thromboembolism (VTE) prophylaxis in plastic surgery. Aesthetic Surgery Journal 26, 157–175. https://doi.org/10.1016/j.asj.2006.02.001 2. Kalmar, C. , Thayer, W. , Kassis, S. , Higdon, K. & Perdikis, G. (2022). Pulmonary Embolism Risk After Cosmetic Abdominoplasty and Functional Panniculectomy. Annals of Plastic Surgery, 89 (6), 664-669. doi: 10.1097/SAP.0000000000003281. 3. Executive Council of ASMBS. Safer through surgery: American Society for Metabolic and Bariatric Surgery statement regarding metabolic and bariatric surgery during the COVID-19 pandemic. Surg Obes Relat Dis. 2020 Aug;16(8):981-982. doi: 10.1016/j.soard.2020.06.003. Epub 2020 Jun 6. PMID: 32565394; PMCID: PMC7274951. 4. Bunch CM, Moore EE, Moore HB, Neal MD, Thomas AV, Zackariya N, Zhao J, Zackariya S, Brenner TJ, Berquist M, Buckner H, Wiarda G, Fulkerson D, Huff W, Kwaan HC, Lankowicz G, Laubscher GJ, Lourens PJ, Pretorius E, Kotze MJ, Moolla MS, Sithole S, Maponga TG, Kell DB, Fox MD, Gillespie L, Khan RZ, Mamczak CN, March R, Macias R, Bull BS, Walsh MM. Immuno-Thrombotic Complications of COVID-19: Implications for Timing of Surgery and Anticoagulation. Front Surg. 2022 May 4;9:889999. doi: 10.3389/fsurg.2022.889999. PMID: 35599794; PMCID: PMC9119324.

Background and Preliminary Data: Targeted muscle reinnervation (TMR) is a procedure that was originally designed to create a strong electrical signal for prosthesis but has recently been found to significantly reduce pain in amputees and traumatic neuromas. Effects on pain were never studied pre-clinically and the mechanism for how TMR provides pain relief remains unknown. As such, there is a fundamental gap in understanding the changes related to pain effected by connecting large mixed motor-sensory nerves to small intramuscular branches. One component of that gap is studying TMR's effects on pain modulation related to timing of the intervention. Our project is unique in that it elucidates the temporal effects of TMR on spontaneous pain behavior. Clinically, these findings may be applied to better optimize pain-related treatment in chronic amputees.

Hypothesis: There will be less noxious pain behavior responses after nerve transection in the group treated with early TMR compared to late TMR interventions. TMR following amputation will not result in analgesia when there is a delay in interventional surgery greater than 6 weeks. 

Methods: Young adult male (200g) Sprague-Dawley rats were randomized into 4 different groups, each with 4 rats. All groups underwent left hindlimb amputation in which the branches of the sciatic nerve were individually ligated. Following amputation at time= 0, delayed TMR was performed at the time indicated by their group:   (1) Group 1: 1 week   (2) Group 2: 3 weeks  (3) Group 3: 6 weeks  (4) Group 4: 9 weeks    All rats were subjected to 4 pain behavioral tests to assess sensitivity to mechanical stimuli (pin test), thermal stimuli (acetone test), and detect spontaneous pain behaviors (guarding, HomeCage). Behavior tests were performed 1 week prior to intervention (pain baseline) and 2 and 4 weeks following TMR. 

Results: There is a decrease in noxious pain behavior responses after 4 weeks across intervention groups that received an intervention in 6 weeks or under. Additionally, rats who received earlier surgical interventions show increased grooming, exploring, sleeping and drinking patterns that better resemble baseline values.

Discussion: This project tested the analgesic effectiveness of TMR against a robust pain phenotype after major nerve injury in rodents. In this model, the pain phenotype in rats that received amputations were significantly reduced in groups with early TMR, which is considered to be 6 weeks or under. These results would mirror clinical applications of limb amputations and the timing of TMR intervention as TMR has been shown to be less effective in chronic amputees.  We are moving forward to further increase the cohort sizes to better understand the effects of TMR with increasing delay. Ultimately, the findings of this project will help us to understand the clinical consequences of delayed TMR in chronic amputees.

Introduction: Free tissue transfers are often completed in patients with high comorbidities, which carry significant risk for postoperative complications, including one or more reoperations. The prevalence of or factors associated with such repeated operations remain uncharacterized. The objective of this study is to understand the prevalence and timing of these reoperations, as well as quantify demographic and clinical predictors of such outcomes.

Methods: The 2013-2022 National Surgical Quality Improvement Program database was queried for free tissue transfer operations based on CPT codes. Records were characterized with demographic, comorbidity, preoperative, and intraoperative variables. The occurrences of one or more unplanned reoperations were characterized by timing after the principal operative procedure and the indication for reoperation. Furthermore, multivariate logistic regression was performed to identify predictors for first and second reoperation (p<0.05).

Results: There were 23,889 free tissue transfer patients who met inclusion criteria, and the most common areas of reconstruction were breast (64%) and head/neck (17.5%). 3,040 (12.7%) patients had one unplanned reoperation, 663 (2.7%) had two unplanned reoperations, and 162 (0.7%) had more than two unplanned reoperations. The rate of thirty-day mortality increased from 0.3% in patients with no reoperation to 1.2% in patients with more than two reoperations. For head and neck procedures, thirty-day mortality increased from 1.08% to 2.43% comparing no reoperations to more than two, and breast procedure thirty-day mortality decreased from 0.04% to 0%. Head and neck reconstruction possessed the highest rates of initial reoperation (16.7%) and second reoperation (4.0%). In head and neck procedures, the most common indication for initial reoperation was vascular repair or reanastomosis (31.2%). In comparison, the most common indication for first reoperation in breast procedures was incision and drainage (37.3%), whereas the most common indication for second reoperation was wound debridement or repair (36.8%). The average time from first to second reoperation was 6.7±6.5 in head/neck and 6.2±7.2 days in breast procedures (p=0.48). Overall, patients who experienced two reoperations had a significantly earlier occurrence of initial reoperation on average (4.9±6.1 days) when compared to those who only experienced one reoperation (8.8±9.1 days) (p<0.001).

The most significant predictors of first reoperation included hypertension, ASA class greater than 2, inpatient setting, smoking history, immunosuppressive therapy, longer operative time, higher body mass index, breast procedure, and longer length of stay (p<0.001). The most significant predictors of second reoperation were longer operative time, higher body mass index, and longer length of stay (p<0.001). Notably, an initial reoperation for vascular repair or reanastomosis also conferred a higher risk for subsequent reoperation (p<0.001).

Conclusions: Prevalence of one or more reoperations in free tissue transfer, as well as associated rates of mortality, is significant. In addition to well-characterized factors like comorbidities and perioperative status, specific regions of reconstruction and indications for initial reoperation may indicate a higher risk for subsequent reoperation, informing general postoperative risk assessment. The association of subsequent reoperations with earlier timing for the first reoperation also supports close postoperative monitoring for patients who experience reoperation in the first week after initial surgery.

Introduction: Axillary lymph node dissection (ALND) is a common procedure used in the treatment of advanced breast cancer that has spread to the regional lymph nodes. One of the untoward and difficult complications of ALND is upper extremity lymphedema (LE). According to the current literature, rates of lymphedema are variable and have been linked to various comorbidities. To address this, Immediate lymphatic reconstruction (ILR) is one of the tools used by reconstructive plastic surgeons at the same time as ALND to abate the incidence of postoperative LE. In this study, we aim to compare rates of lymphedema in patients undergoing ALND with and without ILR at a single institution.

Methods: Patients undergoing ALND at a single institution were reviewed retrospectively. Lymphedema Index (L-Dex) score was used to identify patients with lymphedema. Patient demographics, BMI, comorbidities, lymphedema onset time (days), and number of lymphatic bypasses were noted. Categorical data was analyzed using Pearson's Chi-square test and multivariable logistic regression was performed for factors associated with lymphedema. Odds ratio was used to compare the incidence of LE with and without ILR.

Results: In our cohort, 186 patients underwent ALND; 44 (24%) underwent ALND with ILR and 142 (76%) only ALND alone. Out of the patients undergoing ILR, 8 patients (18%) developed LE, compared to 44 patients (31%) without ILR. In patients who developed LE in the ILR group, mean onset of lymphedema was 543 days compared to 389 days in the cohort without ILR. In patients undergoing ILR, the mean number of lymphatic bypasses performed was 3.54. On multivariate analysis, the number of lymph nodes (LN) dissected was found to be a significant predictor for lymphedema in the non-ILR cohort (p=.025). In both cohorts, patient age, ethnicity, BMI, and number of bypasses performed were not found to be significant in the incidence of LE. The mean follow-up for each patient undergoing ALND with and without ILR was 3.2 years.

Conclusion: In our cohort, we found that immediate lymphatic reconstruction demonstrated a decreased rate of lymphedema in patients undergoing ALND and ILR than ALND alone. In this study, the odds of developing lymphedema in the ILR cohort were 51% less than ALND alone. There was an increased incidence of lymphedema with ALND that contained > 19 LN. In our subgroup analysis, we found ILR to be protective against lymphedema as the patients that did develop LE in the ILR cohort developed LE on average 8 months later than the ALND alone group. Immediate lymphatic reconstruction may be a valuable tool to minimize the incidence of lymphedema and should be considered as an option when treating advanced breast cancer in patients receiving ALND.

Background: Revascularization in patients at risk of critical limb ischemia is integral for limb salvage and prevention of future amputation(1). Local flaps of the foot and ankle remains a versatile tool in reconstructive limb salvage for the atraumatic and chronic wound population. In patients with diseased vessels, a debate remains whether local flap success necessitates direct arterial flow to the respective angiosome. Our study aims to compare the outcomes of local flaps who received direct (DR) or indirect (IR) revascularization in a highly comorbid population with advanced arterial disease.

Methods: Patients who received endovascular revascularization (ER) prior to local flap reconstruction for chronic wounds in the foot and ankle were retrospectively reviewed. Preoperative angiograms were reviewed to determine the location of ER. Patients were compared by direct revascularization (DR)on the same pedicle used for the local flap, or by indirect revascularization (IR), where ER was performed in a different angiosome than the pedicle used for the local flap. Patient demographics, Charlson Comorbidity Index (CCI), angiographic details, minor complications, major outcomes requiring reoperation, and long-term outcomes were collected.

Results: There were a total of 33 patients who received ER in the LE prior to local flap reconstruction, with 57.6% (n=19) receiving DR and 42.4% (n=14) receiving IR. Overall, patients had a mean CCI of 6.7 (SD:1.8), high prevalence of diabetes mellitus (80.4%), peripheral arterial disease (90.9%), and end-stage renal disease (33.3%) with no significant differences between groups. History of vascular bypass was more frequent, but not significant, in the IR group (35.7% vs. 15.8%, p=0.238). On preoperative angiogram, abnormalities showed that the IR group had significantly higher proportions of diseased posterior tibial vessels (p=0.037) and diseased peroneal vessels (p=0.037). There were no significant differences in immediate flap success (DR:100% vs. IR:88.9%, p=0.169) or partial flap necrosis between postoperative day zero to 12 (DR:0.0% vs. IR:16.7%, p=0.066). Rates of major complications from infection (DR:28.2% vs. IR:22.2%, p=0.736), ischemia (DR:4.0% vs. IR:11.1%, p=0.562), or dehiscence (DR:8.0% vs. IR:16.7%, p=0.634) requiring reoperation were similar between two groups. Overall limb salvage (LS) rate was 70.0%, and comparable between groups (DR:68.0% vs. IR 72.2%, p-0.766).

Conclusion: DR and IR are viable ways to perfuse the foot and achieve similar rates of limb salvage after local flap reconstruction. There were no significant differences in rates of immediate flap success or major complications between DR and IR groups. However, this patient population represents a highly comorbid population with ubiquitous histories of diabetes and peripheral vascular disease. A multidisciplinary vasculo-plastic approach should be utilized for these patients preoperatively to optimize bloodflow and postoperatively with close long-term follow-up.

References: 1. Elgzyri T, Larsson J, Nyberg P, Thorne J, Eriksson KF, Apelqvist J. Early revascularization after admittance to a diabetic foot center affects the healing probability of ischemic foot ulcer in patients with diabetes. Eur J Vasc Endovasc Surg. . 2014;48(4):440-6. doi:10.1016/j.ejvs.2014.06.041, 10.1016/j.ejvs.2014.06.041