Received: 24 June 2019 Revised: 11 November 2019
DOI: 10.1002/micr.30556
RESEARCH ARTICLE
Larger free flap size is associated with increased complications
in lower extremity trauma reconstruction
Z-Hye Lee MD1 | Salma A. Abdou MD1 | Elie P. Ramly MD1 |
David A. Daar MD1 | John T. Stranix MD2 | Lavinia Anzai MD1 |
Pierre B. Saadeh MD1
1
Hansjörg Wyss Department of Plastic
Surgery, NYU Langone Health, New York,
New York
2
Department of Plastic and Maxillofacial
Surgery, University of Virginia Health,
Charlottesville, Virginia
Correspondence
Z-Hye Lee, Hansjörg Wyss Department of
Plastic Surgery, NYU Langone Health,
222 East 41st Street, New York, NY 10016.
Email: z-hye.lee@nyulangone.org
Microsurgery. 2020;1–6.
Accepted: 26 December 2019
| Jamie P. Levine MD1 | Vishal D. Thanik MD1
Abstract
Background: Free flap reconstruction after lower extremity trauma remains challeng-
ing with various factors affecting overall success. Increasing defect and flap size have
been demonstrated to be a surrogate for overall injury severity and correlated with
complications. In addition, larger free flaps that encompass more tissue theoretically
possess high metabolic demand, and may be more susceptible to ischemic insult.
Therefore, the purpose of our study was to determine how flap size affects microsur-
gical outcomes in the setting of lower extremity trauma reconstruction.
Methods: Retrospective review of 806 lower extremity free flap reconstructions per-
formed from 1979 to 2016 among three affiliated hospitals: a private university hos-
pital, Veterans Health Administration Hospital (VA), and a large, public hospital
serving as a level 1 trauma center for the city. Soft tissue free flaps used for below
the knee reconstructions of traumatic injuries were included. A receiver operating
curve (ROC) was generated and Youden index was used to determine the optimal
flap size for predicting flap success. Based on this, flaps were divided into those
smaller than 250 cm2 and larger than 250 cm2. Partial flap failure, total flap failure,
takebacks, and overall major complications (defined as events involving flap compro-
mise) were compared between these two groups. Multivariate logistic regression was
performed to determine whether flap size independently predicts complications and
flap failures, controlling for injury-related and operative factors.
Results: A total of 393 patients underwent lower extremity free tissue transfer. There
were 229 flaps (58.2%) with size <250 cm2 and 164 flaps (41.7%) ≥ 250 cm2. ROC anal-
ysis and Youden index calculation demonstrated 250 cm2 (AUC 0.651) to be the cutoff
free flap for predicting increasing flap failure. Compared to flaps with less than 250 cm2,
larger flaps were associated with increased major complications (33.6% vs. 50.0%,
p = .001), any flap failure (11.8% vs. 25.0%, p = .001) and partial flap failure (4.8%
vs. 14.6%, p = .001). Logistic regression analysis controlling for age, flap type, era of
reconstruction, number of venous anastomoses, presence of associated injuries, pres-
ence of a bone gap, vessel runoff, and flap size identified increasing flap size to be inde-
pendently predictive of major complications (p = .05), any flap failure (p = .001), partial
flap failure (p < .001), and takebacks (p = .03). Subset analysis by flap type demonstrated
that when flap size exceeded 250 cm2, use of muscle flaps was associated with
wileyonlinelibrary.com/journal/micr © 2020 Wiley Periodicals, Inc. 1
2 LEE ET AL.

significantly increased flap failure rates (p = .008) while for smaller flap size, there was no
significant difference in complications between muscle and fasciocutaneous flaps.
Conclusion: Increasing flap size is independently predictive of flap complications. In
particular, a flap size cutoff value of 250 cm2 was associated with significantly
increased flap failure and complications particularly among muscle-based flaps.
Therefore, we suggest that fasciocutaneous flaps be utilized for injuries requiring
large surface area of soft tissue reconstruction.

1 | I N T RO DU CT I O N determine the effect of free flap size on complication rates. We

Recent advances in wound care and microsurgical reconstruction
techniques have improved limb salvage outcomes following traumatic
lower extremity injuries, with success rates reported as high as 95%
(Francel, Vander Kolk, Hoopes, Manson, & Yaremchuk, 1992; Yazar,
Lin, Lin, Ulusal, & Wei, 2006). Despite this, lower extremity recon-
structions experience higher overall complications as compared to
other anatomic sites, as they often result from high-impact trauma
resulting in significant bone loss and are prone to vascular compro-
mise and high rates of infection (Culliford et al., 2007; Harashina,
hypothesized that, even accounting for extent of vascular injury,
there is a positive correlation between free flap size and failure rates.
Since this is likely due to the greater metabolic demand of larger
flaps impairing the ability to tolerate vascular compromise, we fur-
ther hypothesized that increasing venous outflow would decrease
flap failure rates in these larger flaps and that large muscle flaps
would be more susceptible to flap failures compared to fasci-
ocutaneous flaps.
TABLE 1 Patient demographics and flap characteristics

1988). There is well-established evidence with regards to patient fac- Flap size Flap size
tors (e.g., smoking and diabetic status) as well as injury-related factors <250 cm2 ≥250 cm2 p value
(e.g., zone of injury, extent of vascular injury) that significantly Total patients, n (%) 229 (58.3%) 164 (41.7%) –
increase complications following free flap reconstruction. However, Mean age, years 36.9 ± 17.0 35.4 ± 14.6 0.357
few studies have evaluated the effect of flap-related variables—specif- Male, n (%) 164 (72.6%) 129 (78.7%) 0.918
ically, free flap size—on reconstructive outcomes in traumatic lower Timing within cohort, n (%) 0.094
extremity reconstruction. To date, most studies have been composed
First era (1976–1996) 126 (55.0%) 102 (62.2%)
of small case series utilizing soft tissue defect size as a surrogate for
Second era (1997–2016) 103 (45.0%) 62 (37.8%)
flap size. Larger flap size is associated with higher metabolic demand
Anatomic location, n (%) 0.280
and is thus, in theory, more sensitive to vascular insult, potentially
Leg injury 140 (61.1%) 109 (66.5%)
posing as a risk factor for increased flap complications. In particular,
Foot injury 89 (38.9%) 55 (33.5%)
both distal necrosis or tissue volume loss and atrophy can occur with
large flaps can as in deep inferior epigastric perforator flaps (Rhodius Flap type, n (%) 0.106

et al., 2018). In addition, the concept of vascular delay has been Muscle 156 (68.1%) 124 (75.6%)

widely used by plastic surgeons for centuries to reliably transfer a Fasciocutaneous 73 (31.9%) 40 (24.4%)
greater volume of tissue suggesting that larger flaps inherently require Muscle flaps with skin
more blood flow. However, studies investigating the relationship paddle, n (%)

between the magnitude of the soft tissue defect and flap complica- Skin paddle 38 (24.4%) 41 (33.1%) 0.070

tions have demonstrated conflicting results. In a review of 112 free No skin paddle 118 (75.6%) 83 (66.9%)
flap reconstructions for open tibial fractures, Shea et al. found a nearly Arterial injury, n (%) 67 (29.3) 72 (43.9) 0.003
three-fold increase in wound complications in defects ≥200 cm , with
2
Associated injury, n (%) 35 (15.3%) 32 (19.5%) 0.168
no correlation between defect size and reoperation rate (Shea et al., Bone gap, n (%) 25 (10.9%) 23 (14.0%) 0.220
2018). In direct contradiction, Shasti et al. (2017) found significantly Exposed hardware, n (%) 26 (11.2) 3 (6.3) 0.120
increased flap failures and reoperations in defects ≥200 cm2. While Venous anastomoses, n (%)
magnitude of the soft tissue defect can arguably be utilized as a surro-
1 vein 160 (69.9%) 128 (78.0%) 0.071
gate for flap size, such investigations do not account for potential con-
2 veins 69 (30.1%) 36 (22.0%)
founding factors such as flap type (i.e., muscle vs. fasciocutaneous),
Arterial anastomosis, n (%)
extent of vascular injury, and intraoperative anastomotic details, all of
End-to-end 113 (49.3%) 116 (50.7%) 0.072
which can contribute to the observed outcomes.
End-to-side 96 (58.5%) 68 (41.5%)
In light of this, we reviewed all free flaps performed at our insti-
tution for traumatic distal lower extremity reconstruction to Note: n, number. Bold values are p-value < 0.05.
LEE ET AL. 3

2 | P A T I E NT S A N D M E TH O D S continuous flow on preoperative angiogram and/or intraoperative

After obtaining institutional review board approval, we retrospectively
reviewed a prospectively maintained institutional database of
806 lower extremity free flap reconstructions performed from 1979 to
2016 among three affiliated hospitals: a private university hospital, Vet-
erans Health Administration Hospital (VA), and a large, public hospital
serving as a level 1 trauma center for the city. Soft tissue free flaps used
for below the knee reconstructions of traumatic injuries were included.
Data collection included patient demographics, vascular injury status and
operative details, including flap type (i.e., muscle vs. fasciocutaneous), flap
size, anastomotic details (e.g., end-to-end vs. end-to-side arterial anasto-
mosis, number of venous anastomoses, etc.), and perioperative complica-
tions. Flap size was calculated by multiplying the width and length of the
flap at its widest dimensions in centimeters.
Major complications were defined as events involving flap com-
promise and included take-backs, partial flap failures, and total flap
failure. Partial flap failures were defined as those requiring an addi-
tional surgical procedure related to wound breakdown or need for flap
debridement during the first 3 months after free flap coverage. Total
flap failure was defined as flap compromise requiring complete
debridement during the index hospitalization. Takebacks were defined
as emergent return to the operating room due to suspected flap vas-
cular compromise. Arterial injury was defined as the disruption of
TABLE 2 Flap choice by subtype
Flap type Number of flaps (%)
Muscle-based flaps (n = 280)
Latissimus dorsi 140 (50.0%)
Rectus abdominis 86 (30.7%)
Gracilis 30 (10.7%)
Serratus 13 (4.6%)
Tensor fascia lata 9 (3.2%)
Other 2 (0.7%)
Fasciocutaneous flaps (n = 113)
identification of significant arterial trauma.
2.1 | Statistical analysis
A receiver operating curve (ROC) was generated and Youden index
was used to determine the optimal flap size for predicting flap suc-
cess. Based on this, flaps were divided into flaps smaller than 250 cm2
and larger than 250 cm2 in size. Univariable associations between flap
size and study outcomes were analyzed using Pearson's Chi-square
test for categorical variables. Multivariate logistic regression control-
ling for relevant variables was performed. These included flap type
(muscle vs. fasciocutaneous), the era of reconstruction, number of
venous anastomose, presence of arterial injury, associated injuries,
vessel runoff, bone gap, and flap size. These variables were chosen to
account for the injury severity (presence of arterial injury, associated
injuries, vessel runoff, and bone gap) or chosen based on previous
studies that have demonstrated their association to flap failure or flap
takeback. A p value <.05 was considered significant. All descriptive
and statistical analysis was performed using SPSS version 25.0 (IBM,
Armonk, NY).
3 | RE SU LT S
A total of 393 patients with below the knee traumatic injury met inclu-
sion criteria. ROC analysis and Youden index calculation demonstrated
250 cm2 (area under the curve, 0.651) to be the cutoff free flap size for
predicting increased odds of flap failure. There were 229 (58.2%) flaps
<250 cm2 and the remaining 164 (41.7%) flaps were ≥250 cm2 in size.
Preoperative patient and injury characteristics, operative factors, and
postoperative complications by flap size are shown in Table 1. There
were no significant differences in patient age, sex, era of reconstruction,
anatomic location of injury, or flap type. A higher number of patients
receiving flaps ≥250 cm2 in size had arterial injury (43.9% vs. 29.3%;

Parascapular 59 (52.2%) p = .003). In addition, there were no differences in other associated inju-
ries, presence of bone gap, or exposed hardware, number of venous
Anterolateral thigh 27 (23.9%)
anastomoses and type of arterial anastomosis. Flap choice by subtype is
Groin 12 (10.6%)
shown in Table 2. Overall, there was a higher number of muscle-based
Lateral arm 6 (5.3%)
flaps compared to fasciocutaneous flaps with the most common being
Other 9 (8.0%)
latissimus dorsi (50.0%), rectus abdominis (30.7%), and gracilis (4.6%).

TABLE 3 Univariate analysis of flap outcomes

Total (n = 393) Flap size < 250 cm2 (n = 229) Flap size ≥ 250 cm2 (n = 164) p value
Major complication, n (%) 159 (40.5%) 77 (33.6%) 82 (50.0%) 0.001
Any flap failure, n (%) 68 (17.3%) 27 (11.8%) 41 (25.0%) 0.001
Total failure, n (%) 33 (8.4%) 16 (7.0%) 17 (10.4%) 0.234
Partial failure, n (%) 35 (8.9%) 11 (4.8%) 24 (14.6%) 0.001
Operative Takebacks, n (%) 61 (15.5%) 32 (14.0%) 29 (17.7%) 0.317

Note: p values determined using one-way ANOVA or Chi (Yazar et al., 2006) tests. Bold values are p-value < 0.05.
4 LEE ET AL.

TABLE 4 Subset analysis of complications for different flap sizes according to flap type

Characteristic Muscle-based flap Fasciocutaneous flap p-value

2
Flap size < 250 cm
Total (n) 156 73
Major complication, n (%) 36 (23.1%) 24 (32.9%) 0.080
Partial flap failure, n (%) 8 (5.1%) 3 (4.1%) 0.513
Total flap failure, n (%) 11 (7.1%) 5 (6.8%) 0.598
Any flap failure, n (%) 19 (12.2%) 8 (11.0%) 0.490
Takebacks, n (%) 17 (10.9%) 15 (20.5%) 0.042
Flap size ≥ 250 cm2
Total (n) 124 40
Major complication, n (%) 45 (36.3%) 13 (32.6%) 0.407
Partial flap failure, n (%) 22 (17.7%) 2 (5.0%) 0.035
Total flap failure, n (%) 15 (12.1%) 2 (5.0%) 0.163
Any flap failure, n (%) 37 (29.8%) 4 (10.0%) 0.008
Takebacks, n (%) 18 (14.5%) 11 (27.5%) 0.055

Note: Bold values are p-value < 0.05.

TABLE 5 Multivariate analysis of flap outcomes

Any flap failure Total flap failure Partial flap failure Takeback Major complications

Age
Flap type (muscle vs. FC)
Initial era of reconstruction 1.21 (0.67–2.18)
Dual venous anastomosis
Arterial injury
Associated injuries
Increasing vessel runoff
Bone gap
Flap size (cm2)
OR p OR p OR p OR p OR p
1.00 (0.98–1.02) 0.76 0.99 (0.97–1.02) 0.61 1.00 (0.98–1.03) 0.87 1.00 (0.98–1.02) 0.84 1.00 (0.98–1.01) 0.80
1.87 (0.90–3.86) 0.09 1.67 (0.66–4.22) 0.28 1.73 (0.60–4.97) 0.31 0.37 (0.20–0.69) 0.002 0.70 (0.42–1.16) 0.23
0.53 1.58 (0.70–3.54) 0.27 0.91 (0.42–1.97) 0.81 2.29 (1.21–4.33) 0.01 1.18 (0.74–1.86) 0.49
0.98 (0.48–1.98) 0.95 0.62 (0.26–1.45) 0.27 1.85 (0.58–5.86) 0.30 1.29 (0.65–2.57) 0.47 1.13 (0.66–1.91) 0.66
0.48 (0.19–1.23) 0.12 1.06 (0.28–4.00) 0.93 3.70 (1.12–12.0) 0.03 0.81 (0.29–2.28) 0.69 1.51 (0.16–14.1) 0.72
0.87 (0.43–1.77) 0.57 0.36 (0.10–1.27) 0.12 1.58 (0.69–3.63) 0.27 1.77 (0.76–4.09) 0.18 1.56 (0.83–2.95) 0.17
0.94 (0.57–1.53) 0.87 0.65 (0.34–1.23) 0.19 1.33 (0.69–2.55) 0.40 0.91 (0.52–1.57) 0.73 1.09 (0.69–1.72) 0.71
1.55 (0.72–3.32) 0.26 1.41 (0.50–4.00) 0.52 1.46 (0.56–3.80) 0.44 1.47 (0.65–3.33) 0.35 1.07 (0.54–2.13) 0.84
1.002 (1.001–1.004) 0.001 1.00 (0.99–1.00) 0.36 1.003 (1.001–1.005) <0.001 1.00 (1.000–1.003) 0.03 1.57 (1.00–2.49) 0.05

Note: Bold values are p-value < 0.05.

Abbreviations: OR, odds ratio; CI, confidence interval; p, p value.

Parascapular (52.2%) and anterolateral thigh flaps (23.9%) were the most
commonly used fasciocutaneous flaps.
Complications occurred in 159 (40.5%) flaps with 35 partial losses
and 33 total losses. On univariate analysis (Table 3), flap size ≥250 cm
was associated with increased complications (p = .001) and any flap fail-
ure (p = .001). Subset analysis by flap type (Table 4) revealed this associa-
tion to be primarily driven by the muscle flap cohort. No significant
association between flap size and major complications (p = .08), partial
flap failure (p = .51), or total flap failures (p = .60) among fasciocutaneous
flaps was observed. For smaller flaps <250 cm2, there was no significant
difference in major complications (p = .08), partial flap failure (p = .51), or
total flap failures (p = .60) between muscle and fasciocutaneous flaps.
However, for larger flaps ≥250 cm2, fasciocutaneous flaps were associ-
ated with a significant decrease in partial flap failures (p = .035). In addi-
tion, for flap size ≥250 cm2, two venous anastomoses compared to
single venous anastomosis was associated with lower partial flap failure
rates (18.0 vs. 2.8%, p = .014). The number of veins did not affect total
flap failure or takeback rates.
Multivariate logistic regression analysis (Table 5) controlling for
age, flap type, cohort era, number of venous anastomoses, presence
of associated injuries, presence of a bone gap, vessel runoff, and flap
2
size identified increasing flap size to be independently predictive of
major complications (p = .05), any flap failure (p = .001), partial flap
failure (p < .001), and unplanned return to OR (p = .03).
4 | DI SCU SSION
Free tissue transfer has become the gold standard for reconstruction
of traumatic injuries of the lower extremity due to its ability to intro-
duce healthy, well-vascularized tissue, obliterate dead space, and
promote bone healing in these often large and complex defects
(Bibbo et al., 2015; Parrett, Matros, Pribaz, & Orgill, 2006; Yazar
et al., 2006). Despite relatively favorable outcomes, this region suf-
fers higher complication and flap failure rates compared to other
anatomic sites (Harashina, 1988). In our study, we identified
LEE ET AL.
increasing flap size as an independent risk factor for major complica-
tions and any flap failure.
Flap size can be considered a surrogate for not only zone of
injury, but also extent of other tissue involvement, such that larger
flaps are more likely to be used for injuries involving bone and muscle
compartment loss and arterial injury (Shasti et al., 2017). Larger
defects are also more likely to require additional debridements and
wound therapy before definitive coverage. To account for these
potential confounding factors, we only included soft tissue flaps
(i.e., excluding osteocutaneous flaps). Based on our analysis using the
receiver operating characteristic curve, flap size ≥250 cm was found
2
to be the cutoff associated with decreased flap which was the basis
for our patient groups for analysis. Furthermore, while there was sig-
nificantly increased rate of arterial injury in the group with flap size
≥250 cm , logistic regression analysis controlling for presence of arte-
2
rial injury revealed flap size to be an independent predictor of flap fail-
ure. These findings suggest that inherent characteristics related to
flaps of larger size are, in part, responsible for the increased complica-
tions in addition to injury severity factors (i.e., presence of arterial
injury) (Stranix et al., 2017).
Larger free flap size is associated with increased metabolic
demand and is thus more sensitive to vascular insult (Thornton, 2004).
While this lends increased flap size to be considered a risk factor for
flap failure, no census has been reached in the literature regarding an
absolute cutoff for increased complications. Our analysis revealed a
flap size threshold of 250 cm2 after which there is an increased risk of
flap failure. This is larger than the previously identified cutoffs of both
flap and defect sizes (Myers & Ahn, 2014; Shasti et al., 2017; Shea
et al., 2018). A 2018 systematic review and meta-analysis looking spe-
cifically at freestyle perforator flaps found no significant difference in
2
complications between flap sizes smaller and larger than 100 cm
(Qian et al., 2018). Notably, this analysis encompassed mail anatomic
sites, with lower extremity reconstructions making up less than 25%
of flaps. Looking specifically at soft tissue defects in the distal lower
2
extremity, previous studies have selected 200 cm as an arbitrary cut-
off for “larger” flaps, with conflicting results (Shasti et al., 2017; Shea
et al., 2018). Our study differs in that the 250 cm2 threshold was cal-
culated with a larger sample size using a ROC analysis to balance sen-
sitivity and specificity for predicting any flap failure.
It is important to note that the increase in complications seen
with larger flaps was driven primarily by muscle-based flaps, which
had higher partial flap failure rates as compared to fasciocutaneous
flaps. An important advantage of fasciocutaneous flaps is that it is
much easier to identify tissue that is suspicious for inadequate vascu-
larity compared to muscle-based flaps. Questionable, hypoperfused
portions can readily be removed intraoperatively while the real time
assessment of circulation is not as clear-cut for muscle-based flaps. It
is important to note that in our cohort, the latissimus dorsi muscle flap
was potentially most readily used to cover extensive soft tissue
defects due to its large surface area. We therefore propose that for
lower extremity traumatic defects requiring a large area of soft tissue
coverage, fasciocutaneous flaps should be favored over muscle-based
flaps, specifically the latissimus dorsi flap. For smaller flaps, there did
5
not appear to be a significant difference in complications between
muscle versus fasciocutaneous flaps and therefore for smaller defects,
flap choice should be tailored to the patient. Finally, previous studies
have demonstrated that for muscle flaps, two veins are protective
against partial flap failures and therefore dual venous anastomoses
should be attempted whenever possible (Stranix et al., 2016). It is well
accepted that skin and adipose tissue have less metabolic demand
than muscle and therefore fasciocutaneous flaps compared to their
muscle-based counterparts of equal size have decreasing blood circu-
lation requirements. This fact may become more clinically relevant in
large flaps and may be the primary factor which allows fasci-
ocutaneous flaps to better withstand vascular insult incurred during
flap compromise with lower partial flap failure rates. In addition, mus-
cle compared to other tissue types is known to have a lower tolerance
to ischemia as demonstrated in the upper extremity replantation liter-
ature (Lin et al., 2010). Warm ischemia time of as little as 2–4 hr can
lead to damage on the cellular level and ultimately tissue loss. This
may help explain the difference in higher rates of flap failure for large
muscle vs. large fasciocutaneous flaps. In large flaps, specifically
greater than 250 cm2 as demonstrated in this study, an ischemic insult
to a segment of muscle with inherently less robust blood supply due
to its large size may be less well tolerated compared to a piece of skin
or adipose tissue.
Flap choice is dictated mainly by the dimensions of a defect and
surgeon preference. Driven by the vasculature and donor site consid-
erations, some types of flaps are inherently limited in their size. In
addition, perfusion of muscle flaps is dependent on the vasculature
pattern as detailed by the Mathes and Nahai and the reliability of dif-
ferent flaps have been well studied in the literature (Mathes & Nahai,
1982). Muscle flaps have historically been the mainstay of lower
extremity reconstruction, however, there has been a recent paradigm
shift towards fasciocutaneous flaps with studies demonstrating similar
clinical outcomes between the two flap types (Cho et al., 2018; Mehta
et al., 2018; Nazerali & Pu, 2013; Yazar et al., 2006). While this study
does not answer the question of which flap type is ideal for lower
extremity coverage, it contributes a valuable datapoint to help guide
flap selection, especially for more severe injuries with a substantial
soft tissue deficit. Of note, takeback rates were higher in fasci-
ocutaneous flaps compared to muscle-based flaps (23.0 vs. 12.5%),
which is consistent with our prior studies demonstrating fasci-
ocutaneous flaps to be 2.3 times more likely to return to the operating
room due to earlier and easier visual recognition of flap compromise
(Stranix et al., 2018). Notably, the addition of a skin paddle in muscle
flaps improves visual monitoring of vascular compromise, but also
increases the flap's metabolic demand which can contribute to partial
flap failure rates (Stranix, Jacoby, Lee, et al., 2018).
This study is not without its limitations, most of which are inher-
ent to its retrospective nature (e.g., lack of consideration of preopera-
tive risk factors such as patient comorbidities, unaccounted-for
selection bias with regards to the intraoperative decision-making pro-
cess that guided flap selection, unknown post-operative protocol
including anticoagulation regimen). Flap size in this study was calcu-
lated as flap length × width (i.e., two-dimensional surface area)
6 LEE ET AL.
without taking into account flap weight or height to determine vol-
ume. In addition, for perforator flaps, we did not have specific infor-
mation on the number of perforators that were utilized relative to flap
size. Within these limitations, however, this study represents the larg-
est case series to date evaluating the relationship between flap size
and survival in traumatic distal lower extremity reconstruction. More
importantly, we identified that large muscle flaps ≥250 cm2 are at
increased risk for complications, which is a valuable piece of evidence
when reconstructing these large and complex defects.
5 | C O N CL U S I O N
Increasing flap size is independently predictive of flap complications.
In particular, a flap size cutoff value of 250cm2 was associated with
significantly increased flap failure and complications, particularly
among muscle-based flaps. Therefore, we suggest that fasci-
ocutaneous flaps be utilized for injuries requiring large surface area of
soft tissue reconstruction.
CONF LICT OF IN TE RE ST
The authors have no financial interest to declare in relation to the
content of this work.
ORCID
Z-Hye Lee https://orcid.org/0000-0001-5096-1959
John T. Stranix https://orcid.org/0000-0002-9770-6127
RE FE R ENC E S
Bibbo, C., Nelson, J., Fischer, J. P., Wu, L. C., Low, D. W., Mehta, S., …
Levin, L. S. (2015). Lower extremity limb salvage after trauma: Versatil-
ity of the anterolateral thigh free flap. Journal of Orthopaedic Trauma,
29(12), 563–568.
Cho, E. H., Shammas, R. L., Carney, M. J., Weissler, J. M., Bauder, A. R.,
Glener, A. D., … Levin, L. S. (2018). Muscle versus Fasciocutaneous free
flaps in lower extremity traumatic reconstruction: A multicenter out-
comes analysis. Plastic and Reconstructive Surgery, 141(1), 191–199.
Culliford, A. T., Spector, J., Blank, A., Karp, N. S., Kasabian, A., &
Levine, J. P. (2007). The fate of lower extremities with failed free flaps:
A single institution's experience over 25 years. Annals of Plastic Sur-
gery, 59(1), 18–21 discussion 21-12.
Francel, T. J., Vander Kolk, C. A., Hoopes, J. E., Manson, P. N., &
Yaremchuk, M. J. (1992). Microvascular soft-tissue transplantation for
reconstruction of acute open tibial fractures: Timing of coverage and
long-term functional results. Plastic and Reconstructive Surgery, 89(3),
478–487 discussion 488-479.
Harashina, T. (1988). Analysis of 200 free flaps. British Journal of Plastic
Surgery, 41(1), 33–36.
Lin, C. H., Aydyn, N., Lin, Y. T., Hsu, C. T., Lin, C. H., & Yeh, J. T. (2010
Mar). Hand and finger replantation after protracted ischemia (more
than 24 hours). Annals of Plastic Surgery, 64(3), 286–290.
Mathes, S. J., & Nahai, F. (1982). Clinical applications of muscle and
musculocutaneous flaps. St Louis: Mosby.
Mehta, D., Abdou, S., Stranix, J. T., Levine, J. P., McLaurin, T.,
Tejwani, N., … Leucht, P. (2018). Comparing radiographic progression
of bone healing in Gustilo IIIB open tibia fractures treated with mus-
cle versus fasciocutaneous flaps. Journal of Orthopaedic Trauma, 32
(8), 381–385.
Myers, L. L., & Ahn, C. (2014). Does increased free flap size in the head
and neck region impact clinical outcome? Journal of Oral and Maxillofa-
cial Surgery, 72(9), 1832–1840.
Nazerali, R. S., & Pu, L. L. (2013). Free tissue transfer to the lower extrem-
ity: A paradigm shift in flap selection for soft tissue reconstruction.
Annals of Plastic Surgery, 70(4), 419–422.
Parrett, B. M., Matros, E., Pribaz, J. J., & Orgill, D. P. (2006). Lower extrem-
ity trauma: Trends in the management of soft-tissue reconstruction of
open tibia-fibula fractures. Plastic and Reconstructive Surgery, 117(4),
1315–1322 discussion 1323-1314.
Qian, Y., Li, G., Zang, H., Cao, S., Liu, Y., Yang, K., & Mu, L. (2018). A sys-
tematic review and meta-analysis of free-style flaps: Risk analysis of
complications. Plastic and Reconstructive Surgery Global Open., 6(2),
e1651.
Rhodius, P., Haddad, A., Matsumine, H., Sakthivel, D., Ackermann, M.,
Sinha, I., … Giatsidis, G. (2018). Noninvasive flap preconditioning by
foam-mediated external suction improves the survival of fasci-
ocutaneous axial-pattern flaps in a type 2 diabetic murine model. Plas-
tic and Reconstructive Surgery, 142(6), 872e–883e.
Shasti, M., Jauregui, J. J., Malik, A., Slobogean, G., Eglseder, W. A., &
Pensy, R. A. (2017). Magnitude of soft-tissue defect as a predictor of
free flap failures: Does size matter? Journal of Orthopaedic Trauma, 31
(12), e412–e417.
Shea, P., O'Hara, N. N., Sprague, S. A., Bhandari, M., Petrisor, B. A.,
Jeray, K. J., … Pensy, R. A. (2018). Wound surface area as a risk factor
for flap complications among patients with open fractures. Plastic and
Reconstructive Surgery, 142(1), 228–236.
Stranix, J. T., Anzai, L., Mirrer, J., Hambley, W., Avraham, T., Saadeh, P. B.,
… Levine, J. P. (2016). Dual venous outflow improves lower extremity
trauma free flap reconstructions. The Journal of Surgical Research, 202
(2), 235–238.
Stranix, J. T., Jacoby, A., Lee, Z. H., et al. (2018). Skin paddles improve mus-
cle flap salvage rates after microvascular compromise in lower extrem-
ity reconstruction. Annals of Plastic Surgery, 81(1), 68–70.
Stranix, J. T., Lee, Z. H., Jacoby, A., Anzai, L., Avraham, T., Thanik, V. D., …
Levine, J. P. (2017). Not all gustilo type IIIB fractures are created equal:
Arterial injury impacts limb salvage outcomes. Plastic and Reconstruc-
tive Surgery, 140(5), 1033–1041.
Stranix, J. T., Lee, Z. H., Jacoby, A., Anzai, L., Mirrer, J., Avraham, T., …
Saadeh, P. B. (2018). Forty years of lower extremity take-backs: Flap
type influences salvage outcomes. Plastic and Reconstructive Surgery,
141(5), 1282–1287.
Thornton, J. F. (2004). Skin grafts and skin substitutes and principles of
flaps. Selected Readings in Plastic Surgery., 10(1), 65–66.
Yazar, S., Lin, C. H., Lin, Y. T., Ulusal, A. E., & Wei, F. C. (2006). Outcome
comparison between free muscle and free fasciocutaneous flaps for
reconstruction of distal third and ankle traumatic open tibial fractures.
Plastic and Reconstructive Surgery, 117(7), 2468–2475 discussion
2476-2467.
How to cite this article: Lee Z-H, Abdou SA, Ramly EP, et al.
Larger free flap size is associated with increased complications
in lower extremity trauma reconstruction. Microsurgery. 2020;
1–6. https://doi.org/10.1002/micr.30556