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Page 2 of 16 Deldar et al. Plast Aesthet Res 2022;9:13 https://dx.doi.org/10.20517/2347-9264.2021.100

(DFU) can cause a devastating impact on patient quality of life in terms of chronic pain, infection,
[4]
decreased ambulation, social distress, and ultimately survival .
LE wound healing complications are a major concern in diabetic patients, with a lifetime incidence of DFU
[7]
[5,6]
as high as 25% . Nearly 75% of all lower limb amputations are performed in diabetic patients . Following
major LE amputation, 5-year mortality rates can reach 56.6%, which are higher than breast, colon, or
[8]
prostate cancer . This is likely due to increased cardiovascular exertion, further decline in functional ability,
and exacerbation of existing comorbidities . Moreover, major LE amputation increases the risk of
[9]
contralateral amputation by up to 50% within two years [10-12] .
Thus, recent advancements in the treatment of chronic LE wounds have focused on limb salvage modalities.
These include local debridement, advanced wound care, revascularization, bony reconstruction, and soft
tissue reconstruction. Planning for soft tissue reconstruction requires careful consideration of several
factors, including patient comorbidities, size and location of the wound, exposed underlying structures, and
in the case of the possible free flap, patency of donor and recipient vessels. This article aims to review the
perioperative considerations, and local and free flap options that are essential to provide successful soft
tissue coverage in the chronic LE wound population.

DISCUSSION
Preoperative optimization
Planning for soft tissue reconstruction requires optimization of patient comorbidities and wound bed
preparation. This should entail a multidisciplinary collaboration amongst providers from different surgical
and medical specialties. These include but are not limited to plastic surgery, orthopedic surgery, vascular
surgery, podiatric surgery, internal medicine, endocrinology, cardiology, and hematology.

From a medical perspective, a thorough history detailing all pre-existing medical conditions should be
obtained. In diabetic patients, tight glycemic control is essential. Patients with perioperative blood glucose
levels greater than 200 mg/dL or hemoglobin A1c > 6.5% are more than three times likely to experience
wound dehiscence [13,14] . Close partnerships with endocrinologists and diabetes educators are important for
long-term blood glucose maintenance. Our team’s goal is to maintain blood glucose levels perioperatively
less than 200 mg/dL. The ideal perioperative HgbA1c is less than 7; however, if a patient’s HgbA1c is greater
than 7, this is not a contraindication to free tissue transfer (FTT) because it may be falsely elevated
perioperatively secondary to hyperglycemia from acute infection. Nutrition labs, including albumin and
prealbumin, should also be obtained preoperatively as malnutrition has negative effects on the wound
healing process [15,16] . Hypoalbuminemia results in delayed tissue healing, reduced collagen synthesis, and a
decrease in plasma colloid osmotic pressure, thereby causing tissue edema and leakage of interstitial fluid,
which mediates bacterial propagation into wounds [15,17] . Our institution previously found that in patients
undergoing FTT, a preoperative albumin level less than 2.7 g/dL was associated with decreased flap healing
outcomes . In general, a low prealbumin level (< 10 mg/dL) is associated with decreased free flap survival
[18]
rate .
[19]
Smoking cessation can reduce the risk of impaired wound healing, infection, partial flap loss, and need for
revision surgery . We encourage patients to refrain from tobacco use for at least four to eight weeks prior
[20]
to reconstructive surgery; however, this may not be possible if the wound requires free flap immediately.
Smoking is not a contraindication for free flap surgery in this population, but the patient must be educated
that delayed healing is likely. In our practice, we also screen patients for inherited or acquired
hypercoagulable traits that may predispose them to thrombosis. A hypercoagulable workup is a subject of