ABSTRACT Introduction Vascular compromise after free anterolateral thigh (ALT) flap reconstruction is a time‐critical event and may result in total flap loss despite re‐exploration. Although earlier re‐exploration is associated with improved salvage, this relationship is often simplified by arbitrary thresholds, and internally validated prediction models remain scarce. We aimed to quantify this relationship and assess the additional predictive value of systemic factors beyond timing. Methods This retrospective single‐center cohort study included all free ALT flaps for post‐traumatic extremity reconstruction between 2005 and 2020 that underwent re‐exploration for suspected vascular compromise on postoperative day (POD) 0–4. The primary endpoint was flap salvage at POD 5. Intraoperative findings were compared between salvaged and failed flaps. Univariable logistic regression examined the association between POD and salvage, followed by a multivariable model with prespecified covariates. Restricted cubic splines assessed nonlinearity, and 1000 bootstrap resamples were used to obtain optimism‐corrected estimates of discrimination and calibration. Results Among 222 ALT flaps, 58 (26.1%) required re‐exploration; 33 (56.9%) were salvaged and 25 (43.1%) failed. Salvage rates were 90.0%, 51.7%, 37.5%, 57.1%, and 50.0% for re‐exploration on POD 0–4, respectively. Arterial and venous compromise were more frequent in failed flaps, without significant differences. Salvage probability crossed the 50% threshold between POD 1 and POD 2. Spline modeling demonstrated significant nonlinearity, with a steeper decline during the first two PODs followed by a relative plateau (LRT p = 0.037). Most systemic variables added little predictive information. Apparent discrimination was moderate (AUC 0.714), and optimism‐corrected performance was modest (AUC 0.622; calibration slope 0.69). Conclusion Salvage probability declined in a biologically plausible, continuous, and nonlinear manner with increasing POD of re‐exploration, with a steeper decline at earlier time points, although salvage remained possible later. Timing appeared to be the principal determinant of salvage, while systemic variables added limited predictive value.
ABSTRACT Background Lymphaticovenous anastomosis (LVA) is an established microsurgical treatment for lymphedema, but predictors of intraoperative vessel characteristics and immediate anastomosis patency remain unclear. This study investigated associations between preoperative patient and disease factors and intraoperative findings during LVA surgery. Methods In this prospective international multicenter study, 183 patients undergoing 426 LVAs were included. Preoperative patient and disease characteristics were recorded. Surgeons documented intraoperative findings using a standardized semiquantitative grading form, assessing lymphatic vessel function and fibrosis, and venous backflow and patency of the immediate anastomosis using intraoperative indocyanine green lymphography (ICG‐L). Accuracy of preoperative ICG‐L markings was also assessed. Associations between preoperative variables and intraoperative findings were analyzed using cumulative link mixed models and negative binomial regression. Results The upper extremity had markedly less lymphatic vessel fibrosis (OR: 10.23, 95% CI: 2.27–45.99, p = 0.002) and greater venous backflow (OR: 0.46 for reduced backflow, 95% CI: 0.22–0.97, p = 0.041). Increased age correlated with more accurate ICG‐L markings (OR: 1.04 per year, 95% CI: 1.00–1.08, p = 0.048) and greater surgeon confidence in immediate LVA patency (OR: 1.02 per year, 95% CI: 1.00–1.05, p = 0.028). Prior radical lymph node dissection reduced surgeon confidence in LVA patency (OR: 0.40, 95% CI: 0.16–0.97, p = 0.042). Body mass index (BMI) > 30 showed a trend toward more venous backflow. Increased patient age (IRR: 1.03 per year, 95% CI: 1.00–1.07, p = 0.026) and lower extremity location (upper‐ vs. lower‐extremity IRR: 0.33, 95% CI: 0.11–0.87, p = 0.020) were associated with more preoperative erysipelas infections. Lymphedema stage (0–2b), etiology and duration, gender, and adjuvant therapy had no significant association with intraoperative findings. Conclusion This multicenter study identified patient age and lymphedema location as factors associated with intraoperative findings in LVA surgery, including infection frequency, lymphatic vessel fibrosis, venous backflow, and surgeon‐reported patency. Lymphedema stage (0–2b), etiology, and duration showed no significant associations. Trial Registration ISRCTN registry number: 72662721
ABSTRACT Background The internal mammary vessels are commonly used as recipient vessels for free flap breast reconstruction. However, inadequate arterial flow may be encountered intraoperatively. This hypothesis‐generating study evaluated the safety and feasibility of activated clotting time (ACT)‐guided systemic heparinization as one component of a salvage strategy in such situations. Methods We retrospectively reviewed consecutive autologous breast reconstructions using the internal mammary artery (IMA) between 2019 and 2025. Based on intraoperative jet bleeding status and intimal findings, IMA vessels were categorized into three groups: normal flow, inadequate flow managed by conventional measures, and inadequate flow subsequently managed by ACT‐guided systemic heparinization. ACT‐guided systemic heparinization targeted an ACT of 200 s. An initial heparin bolus infusion of 36–60 IU/kg was given, followed by ACT measurement 15–30 min later and every 30–60 min thereafter, with additional heparin administered for ACT ≤ 200 s. Clinical outcomes were evaluated and compared. Results A total of 103 IMA vessels (101 patients) were analyzed: 80 (77.7%) in the normal flow group, 17 (16.5%) in the inadequate flow group, and 6 (5.8%) in the ACT‐guided heparinization group. Patient characteristics, aortic calcification, IMA diameter, and blood loss did not differ among groups (all p > 0.05). Postoperative hematoma rate was 2/80 for normal flow, 0/17 for inadequate flow, and 0/6 for ACT‐guided heparinization ( p > 0.05). Median peak ACT was 238 s, and median intraoperative heparin dose was 4758 IU. Despite the significantly longer intraoperative flap ischemia time in the ACT‐guided heparinization group (normal flow: 98.5 min, inadequate flow: 127 min, ACT‐guided heparinization: 208 min; p < 0.01), all six flaps survived. Conclusions As part of intraoperative rescue, ACT‐guided systemic heparinization was employed successfully in 5.8% of IMA vessels in this series. ACT monitoring provides rapid and objective assessment and may represent an additional intraoperative option for suboptimal arterial flow.
ABSTRACT Background The pedicled reverse‐flow posterior interosseous artery (PIA) flap is a reliable option for soft‐tissue reconstruction of the hand and wrist. However, the predictors of complications and the impact of early revision surgery have not been adequately evaluated using multivariable analysis. This study aimed to investigate the factors affecting flap survival, complication rates, and outcomes of salvage surgery. Patients and Methods A retrospective analysis was conducted on 110 patients who underwent reconstruction with a pedicled reverse PIA flap between 2010 and 2025. Univariable and multivariable logistic regression analyses were performed to identify predictors of venous congestion, flap loss, and donor site grafting. Receiver operating characteristic (ROC) analysis was used to determine the dimensional thresholds. Results The mean patient age was 34.2 years, and the majority of defects were traumatic in etiology (80.9%). Venous congestion occurred in 30 patients (27.3%), whereas total and partial flap loss occurred in five (4.5%) and 15 (13.6%) patients, respectively. On multivariable analysis, flap length was independently associated with venous congestion (OR = 1.45, 95% CI 1.17–1.79; p < 0.001) and flap loss (OR = 1.47, 95% CI 1.17–1.85; p < 0.001). ROC analysis identified a flap length of 9 cm as a practical reference threshold (high specificity, modest sensitivity) for these complications. In a separate donor‐site grafting model, flap width > 4 cm was associated with grafting on univariable analysis but became only borderline significant after multivariable adjustment (OR 1.60, 95% CI 0.98–2.60; p = 0.059), while traumatic etiology was independently associated with donor site grafting (OR = 8.00, 95% CI 2.20–29.03). Among patients with venous congestion, early revision was associated with a lower flap loss rate than conservative management (43.75% vs. 92.86%, p = 0.007). Conclusions In reverse‐flow PIA flap reconstruction, greater flap length was independently associated with venous congestion and flap loss. Traumatic etiology emerged as an independent predictor of donor‐site grafting, an association that has received little prior attention. In patients with venous compromise, early revision was associated with a lower overall flap loss rate, although this observational finding requires confirmation in prospective studies.
ABSTRACT Desmoid tumors (DTs) are rare, benign, locally aggressive myofibroblastic neoplasms. Complete resection with negative margins remains the standard treatment despite their lack of metastatic potential. As DT commonly involve the anterior abdominal wall, their excision may result in complex defects requiring advanced reconstruction. We herein present the first functional single‐stage reconstruction of an abdominal wall defect with the use of a free innervated gracilis muscle flap transfer. A 29‐year‐old woman, presented with a palpable tumor on the left‐side of her abdominal wall. She underwent surgery and on biopsy, the tumor was diagnosed as a DT. The patient underwent wide resection through an abdominoplasty approach, which resulted in a rectus abdominis defect involving the anterior rectus abdominis sheath. The 8 × 7cm‐sized defect was reconstructed with free transfer of a neurotized gracilis muscle flap, anastomosed to the deep inferior epigastric vessels, whereas, the anterior branch of the obturator nerve was coapted to the ninth intercostal nerve. Finally, a monofilament polypropylene mesh was used for reconstruction of the missing anterior rectus sheath. Ever since and during a follow‐up of 5 years, electromyographic examinations have demonstrated excellent re‐innervation of the gracilis muscle flap. The patient underwent regular follow‐up examinations, including CT imaging at 1, 2, and 5 years postoperatively, with no evidence of abdominal wall protrusion or tumor recurrence. This case demonstrates that the free innervated gracilis flap can provide a safe and reliable reconstructive option for complex abdominal wall defects following oncologic resection.
