Magnitude of Soft-Tissue Defect as a Predictor of Free Flap Failures: Does Size Matter?

OBJECTIVES: To examine the relationship between the magnitude of soft-tissue defect and the risk of free-flap and limb-salvage complications/failures. DESIGN: Retrospective cohort. SETTING: Level I Trauma Center. PATIENTS: One hundred twelve patients with free tissue transfers between January 2009 and June 2015. INTERVENTION: A standardized approach using a consistent team of 2 orthopaedic microvascular surgeons was used for each free-flap reconstruction. MAIN OUTCOME MEASURE: Soft tissue defect size, total or partial flap failure, and unplanned reoperations. RESULTS: Of 112 free-flap reconstructions, 57 complications occurred in 43-cases (38%) including 5 total flap failures (4.5%), 7 partial flap failures (6%), and 8 early (7%) and 38 delayed complications (33%). There was a significant correlation between the large defect size (≥200 cm) and partial/total flap failure (n = 80, P = 0.023). There was also a significant correlation between large soft tissue defect size and any complication that is, total or partial failure and early or delayed unplanned return to the operating room (n = 80, P = 0.002). Of the flaps used, multivariate analysis revealed that latissimus flaps had higher odds for failure. CONCLUSIONS: Soft-tissue defect size ≥200 cm can be associated with a higher rate of total or partial flap failure and any complication in acute trauma setting, which may be due to a larger zone of injury, a higher level of difficulty in achieving complete debridement, and a more complex microvascular dissection. Current and future efforts will need to continue to focus on risk stratification for limb salvage efforts because an accurate assessment of risk is important to the patient, health care provider, and the health care system in general. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.