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The Fate of Lower Extremities With Failed Free Flaps: A Single Institution's Experience Over 25 Years

Culliford, Alfred T. IV MD*; Spector, Jason MD; Blank, Alan BA; Karp, Nolan S. MD; Kasabian, Armen MD*; Levine, Jamie P. MD

doi: 10.1097/
Original Article

Background: Lower-extremity reconstruction with microvascular free flap coverage is often the only option for limb salvage. Flap failure rates, however, continue to have higher complication rates than those to other anatomic sites; a significant number of flaps that fail result in amputation. This study retrospectively analyzed patients treated at a single institution who underwent attempted lower-extremity limb salvage with microsurgical techniques over a 25-year period. Of particular interest are the outcome data for patients who had initial free flap failure.

Patients and Methods: A prospectively maintained database was used to identify patients who satisfy criteria. Every patient who was treated with a microvascular free flap to their lower extremities was identified and included in this analysis. All records were reviewed from 1980 through 2004. Patients who had free flaps to the lower extremity fail after the initial operation were identified and selected for further analysis.

Results: Five hundred eighty-eight patients who underwent microsurgical reconstruction of lower extremity wounds had a failure rate of 8.5%. Trauma patients (83%) had a failure rate of 9%. On subset analysis, the failure rate for trauma patients decreased from 11% (1980–1992) to 3.7% (1993–2004). Of patients who had a failed free flap, 18% went on to limb amputation; the remainder was salvaged with secondary free flaps, local flaps, or skin grafting.

Conclusion: This single institutional experience spanning 25 years represents the longest continual series of lower-extremity free flaps reported in the literature. The improved success rate seen in the second half of the study period is attributed to a more critical selection of free-flap candidates, improved understanding of the physiology surrounding acute trauma and a more sophisticated multidisciplinary team organization.

A review of 588 lower extremity free-flap reconstructions demonstrated an 8.5% overall flap failure rate with 18% of these going on to amputation. The rate of flap failure in trauma patients was reduced by two-thirds in the later years of the study.

From the *Division of Plastic, Reconstructive and Hand Surgery, Staten Island University Hospital, Staten Island, NY; †Division of Plastic Surgery, Weill Cornell Medical College, New York, NY; and the ‡Institute of Plastic and Reconstructive Surgery, New York University Medical Center, New York, NY.

Received February 13, 2007, and accepted for publication February 15, 2007.

Presented at the Annual Meeting of the Northeastern Society of Plastic Surgeons, Boston, MA, November 30–December 3, 2006.

Reprints: Alfred T. Culliford, IV, MD, Plastic, Reconstructive and Hand Surgery, Staten Island University Hospital, 256C Mason Avenue, 3rd Floor, Staten Island, NY 10305. E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.