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Kovar et al. Plast Aesthet Res 2019;6:10 I http://dx.doi.org/10.20517/2347-9264.2019.09 Page 3 of 9

directly over the pedicle were separated from those reports with skin grafting elsewhere such as the donor
site or atop the flap.

For the purposes of this study, the database was queried in October 2018 for cases performed from January
2014 to December 2017. For each patient, relevant demographic information, comorbidities, presence of
chronic kidney disease, arterial revascularization, anticoagulant use, wound etiology, pre-operative imaging,
anatomical wound location, skeletal fixation, flap thickness, operative characteristics, complications and
follow-up were reviewed.

Guiding principles in lower extremity reconstruction were followed: appropriate debridement to perfused
tissue, preservation of vital structure, muscle, nerve and tendon along with isolation and control of major
vascular inflow. Wounds amenable to local tissue reconstruction with advancement flaps, skin-graft,
regional pedicle flaps, freestyle propeller flaps were utilized when-able but excluded from this study.

During free tissue transfer, we preferentially performed end-end anastomosis in patients with adequate
runoff. However, in settings of critical limb ischemia or compromised in-flow an end to side anastomosis
was performed. We have previously studied an algorithm for venous anastomosis and preferentially utilize
[8]
the deep venous system, avoiding refluxing veins and matching for size .

An enhanced recovery protocol was utilized for the majority of our patients including the use of regional
[10]
[9]
anesthetic block and an early limb dependency program helped patients dangle early in their post-
operative course expediting hospital stay, discharge to rehabilitation facilities, and return toward functional
ambulation.

Primary closure over the pedicle was defined as direct closure of at least the skin layer with tissue from the
recipient site, or in combination with a portion of the flap. Tension was evaluated by the inability to close
the skin and or skin-flap interface with a 3-0 nylon and a double-knot throw, without slipping. Skin grafting
closure required a separate donor site for harvesting the skin graft to place over the fasciocutaneous free
flap to provide an additional layer of coverage. Often, in the case of anterolateral thigh free flaps - we were
able to utilize the dog-ears from the apices of the lateral thigh incision to create a full thickness skin graft
in cases of small (< 6 cm × 6 cm) areas of pedicle exposure. For any larger dimensions a dermatome was
used at 1/14,000 of an inch to place a split thickness skin graft over the pedicle. Thorough attention toward
dressing and splinting the extremity was performed. Xeroform (Covidien, Dublin, Ireland) was placed over
the skin-graft and pedicle construct without a bolster or pressure dressing. The flap and extremity were
wrapped in bulky jones cotton, a plaster splint and ACE to ensure appropriate padding and pressure off-
loading of both flap and pedicle. We monitored the flaps using clinical exam, Doppler probes and Vioptix
(ViOptix Inc. Newark, CA).

Outcome measures
Outcomes pertaining to flap specific morbidity such as partial flap loss, microvascular collapse, vessel
thrombosis, site infection and dehiscence were analyzed in addition to systemic complications as well as
need for operative take-back. Additionally, vascular pedicle exposure and loss of the skin graft were also
analyzed.

Analysis
Descriptive statistics were utilized to compare patient demographic information in regard to number,
frequency, mean and standard deviation. Student t-test for continuous data and Fischer’s exact test for
categorical data were used for univariate analysis to determine significant differences between skin graft and
primary closure groups. Those variables achieving significance P < 0.05 were entered into a multivariable