Osteocutaneous free flaps for reconstruction of composite hand defects: A systematic review of clinical and functional outcomes.

Large joint arthroplasty is among the most frequently performed procedures in orthopaedic surgery. One of the most common and challenging causes of prosthetic failure is periprosthetic joint infection (PJI). Periprosthetic soft tissue damage is often a critical yet underestimated factor influencing surgical outcomes. The aim of our meta-analysis is to evaluate the clinical efficacy, complications, failure rates, and the overall reliability of free flaps as a reconstructive solution. PubMed, Embase, and Google Scholar were searched, according to PRISMA guidelines. Studies were included if they reported healing rate, complications, type of free flaps, and pathogen characteristics. A quality evaluation was performed. The overall effect size was reported as survival rate of the free flaps, and the secondary effect sizes were determined as the rate of reinfection or persistent infection after coverage with free flaps and the amputation rate because of non-controlled infection. The statistical analysis was carried out using the software 'R', version 4.5.0 (2025-04-11). Fourteen papers were included, with a total of 185 observations and 161 events (free flap survived). All papers were retrospective studies. The pooled survival rate was 93% (I 2 = 66.7%). The pooled rate of reinfection or persistent infection after the index surgery was 16% (I 2 = 77.6%). The amputation rate was 8%. Free flaps are a reliable solution to manage tissue loss in patients with periprosthetic infection, but the results could be affected by technical errors and non-skilled intra- and post-operative management. Orthoplastic and microsurgical skills are mandatory to be successful.

Free adipomuscular diagonal upper gracilis flap as volume replacement for reconstruction of partial breast defect in the medial upper quadrant.

Heparin is frequently used to mitigate the risk of thrombosis in microsurgical free tissue transfer. Although rare, heparin-induced thrombocytopenia (HIT) is a severe, life-threatening complication that can arise in patients exposed to heparin products. This systematic review aims to examine patterns in demographics, flap characteristics, diagnostic approaches, and treatment protocols for HIT following free flap reconstruction. A systematic search was conducted across PubMed, MEDLINE, and Web of Science, following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Search terms included "heparin-induced thrombocytopenia," "HIT syndrome," "free flaps," "microsurgery," "plastic surgery," and "reconstructive surgery." Case reports or series written in English that presented patients developing HIT following free flap procedures were included. Eligibility criteria are accessible on the International Prospective Register of Systematic Reviews (PROSPERO; CRD42025650125). A total of 15 articles were included, encompassing a total of 23 free flap reconstruction cases. The median patient age was 52 years, with male predominance (69.6). Lower extremity reconstruction was most common (47.8%), primarily using anterolateral thigh flaps (39.1%). Median 4T score was 6, median time to HIT diagnosis was 6 days, and median nadir platelet count was 72 × 103/μL. Thrombotic complications were common, with venous thrombosis (34.8%) predominating. Argatroban (26.1%) was the most frequently used alternative anticoagulant, while warfarin (30.4%) was the most common discharge medication. Overall flap survival was 43.5%. Meta-analysis revealed no significant difference in flap survival between anticoagulation strategies (95% CI: 0.38-2.63, p = 1.000). HIT represents a rare but devastating complication in free flap reconstruction, with approximately half of the affected flaps failing despite intervention. Although no single anticoagulation strategy demonstrated superior outcomes, expeditious diagnosis and treatment may improve flap salvage rates. This review provides a foundation for developing standardized protocols for HIT management in microsurgical patients.

Restoration of active motion in children with upper-limb paralysis or muscle loss remains challenging. Free functional muscle transfer (FFMT) is a reconstructive option when local muscle donors are unavailable, but uncertainties persist regarding optimal timing, donor nerve selection, and long-term effects of growth and secondary deformities. This study reports a single-institution experience addressing these issues. A retrospective review was conducted of 35 children (<18 years) who underwent upper-limb FFMT with a minimum follow-up of 24 months. All reconstructions used the gracilis muscle to restore finger flexion, elbow flexion, elbow extension, or combined functions. Donor nerves included the anterior interosseous nerve (AIN) with or without median nerve fascicles, intercostal nerves, spinal accessory nerve, and phrenic nerve. Outcomes included time to muscle activation, range of motion, Medical Research Council (MRC) strength, secondary procedures, complications, bimanual use, and patient or caregiver-reported satisfaction. Pre- and postoperative outcomes were compared using paired and groupwise statistical tests. Mean age at surgery was 7.6 years, with a mean follow-up of 68 months (range, 24-166 months). Flap survival was 100%. Initial muscle activation occurred at a mean of 4.1 months. Significant improvements in motion and strength were observed across all functions (p<0.001). MRC grade ≥4 strength was achieved in 80.0% of elbow-flexion reconstructions and 78.3% of finger-flexion reconstructions. Finger-flexion reconstructions demonstrated higher bimanual use and more consistent recovery than elbow-flexion reconstructions. In construct-level analysis, single-function transfers showed clearly superior finger-flexion outcomes, whereas elbow-flexion results differed by endpoint: single-function transfers achieved greater ROM, while all dual-function elbow-flexion transfers reached MRC grade ≥4 in this small subgroup. Secondary procedures were required in 51.4% of patients. Overall satisfaction was reported by 71.4% and correlated more strongly with final strength and completion of reconstruction than with range of motion. Gracilis FFMT provides durable restoration of active motion and strength in children. Outcomes are influenced by indication and reconstructed function rather than donor nerve selection alone. Strength recovery and functional integration are primary determinants of bimanual use and satisfaction. Findings support the use of FFMT as part of a staged reconstructive strategy in pediatric patients.

Chronic Lower Extremity Wounds: Updates on Lower Extremity Reconstruction in Clinics in Plastic Surgery.

The use of vasopressors during microsurgical reconstruction is debated. Their effect on the comorbid lower extremity (LE) wound population is unstudied. This study characterizes the impact of intraoperative vasopressor use in LE free tissue transfer (FTT) for limb salvage. A review of LE FTT from February 2017 to June 2024 was conducted. Flap outcomes within 7 and 42 days were evaluated, as well as long-term limb salvage. Of 258 LE FTT performed, vasopressors were used in 177 cases (68.6%). Most vasopressors were administered via intermittent bolus only (75.7%) or combined with continuous infusion (23.7%). American Society of Anesthesiologists Class was significantly higher in the vasopressor group compared with controls (p = 0.001). The vasopressor group trended to have higher median Charlson Comorbidity Indices (4, interquartile range [IQR]: 3 vs. 3, IQR: 3; p = 0.055), and rates of diabetes (65.0% vs. 54.3%, p = 0.103), peripheral vascular disease (63.8% vs. 51.9%, p = 0.068), and chronic kidney disease (14.7% vs. 6.2%, p = 0.063). The rate of reoperation, microvascular thrombosis, or flap success at 7 and 42 days did not differ between groups. By a median long-term follow-up of 24.5 (IQR: 39.2) months, rates of major limb amputation (vasopressor: 10.7% vs. control: 7.4%, p = 0.402) and mortality (6.8% vs. 2.5%, p = 0.237) were similar between groups. In this complex population, intraoperative use of vasopressors does not appear to negatively impact flap viability or limb salvage.

Lower Extremity Reconstruction in Acute Burns.

Posttraumatic bone defects or their sequels represent one of the most challenging problems in limbs reconstruction. It is proved that due to their advantages, i.e. regenerative properties, shorter time to obtain bone fusion, better stability, better power to fight against infection, the use of vascularized bone grafts (VBGs) represents the best choice in such cases. If large soft tissue defects are concomitant to bone defects, composite flaps including bone segments should be the choice. This paper provides details about such flaps - vascularized rib (R) as part of the latissimus dorsi (LD) and/or serratus anterior (SA) flap. In all alternatives, i.e. LD-R, SA-R, and LD-SA-R, the flap can be used as a free flap in both upper and lower limb, or as a pedicled flap in upper extremity. We hypothesized that these flaps could offer the same advantages and possible results as other VBGs.

The development of appropriate microsurgical and supermicrosurgical skills is essential for reconstructive surgeons. Training courses frequently employ in vivo models, which have various drawbacks: Limited availability, high cost, and/or ethical conflicts. To overcome these limitations, we looked for an inert model that was analogous to the gold standard in vivo, surpassing the classic ex vivo models at the same time. We studied the ex vivo rabbit as an animal training model by means of 10 specimen dissections, microscopically analyzing the mean caliber and length of its main vascular pedicles and comparing them to those of the most common flaps and recipient vessels employed in reconstructive surgery. We designed a routine with increasingly difficult exercises, which we propose as a training plan. The rabbit's main vascular pedicles have a mean caliber of 0.4 mm (internal mammary), 0.8 mm (iliolumbar), 0.9 mm (brachial), 1.2 mm (femoral), 1.5 mm (renal), 1.9 mm (common carotid), and 2.8 mm (aorta). They allow for a progressive increase in the level of complexity, as well as the practice of a wide variety of techniques (end-to-end anastomosis between vessels of different sizes, end-to-side anastomosis, neurorrhaphies, nerve transfers, ortho- and heterotopic replants, and free flaps). The ex vivo rabbit serves as a valid alternative to other recognized high-fidelity microsurgical models, overcoming the limitations of in vivo-it is easily accessible, inexpensive, and inert-as well as ex vivo-it offers a wide range of calibers and the possibility of practicing advanced techniques-models which have been used in the past.

Artificial intelligence-based decision support in simulated free flap Re-exploration for head and neck reconstruction. A case-based comparative study.

Effects of extremely low-frequency sinusoidal electromagnetic field therapy on survival and vascularization in a rat random-pattern skin flap model.

Upper extremity burns comprise a significant proportion of severe burn injuries. Their effective management necessitates a multidisciplinary approach, with early integration of hand surgery specialists. This is a narrative review article of current treatment modalities, prioritizing strategies to minimize acute-phase complications and optimize long-term outcomes. We cover initial management principles including resuscitation, thorough secondary assessment, and prompt debridement; elaborate on reconstructive surgical interventions such as skin grafting and flap techniques, paying close attention to strategies that preserve key anatomic locations for good functional outcomes; and outline common complications such as infection, heterotopic ossification, scar contractures, edema, and compartment syndrome, providing evidence-based prevention and treatment strategies. Although the management of upper extremity burn patients can be complex, utilizing a standardized and meticulous approach to the management of these devastating injuries can result in significantly improved functionality of the upper extremity.

Locoregional Flaps in Lower Extremity Reconstruction: A 2026 Update.

There is no consensus on blood thinner management in the perioperative period for head and neck free flap reconstructions. This study evaluated head and neck free flap outcomes in patients on baseline blood thinners, aspirin flap prophylaxis, and deep venous thrombosis (DVT) prophylaxis regimens. Patients undergoing head and neck free flap reconstruction at a single tertiary, academic institution were included. Patients were grouped according to baseline blood thinners, aspirin flap prophylaxis, and DVT prophylaxis regimens. The primary outcome was overall complication rate, while secondary outcomes included flap compromise, flap failure, bleeding, venous thrombotic events, and arterial thrombotic events. Statistical analysis was performed with Fisher's exact test and risk ratio (RR) regression analysis, using propensity score-adjusted models. Of 470 patients, 16.6% experienced postoperative complications. Longer preoperative holds (odds ratio [OR] = 1.81, p = 0.04) and delayed resumption of baseline blood thinners (OR = 1.56, p = 0.04) were associated with increased complication risk, particularly flap compromise. Unfractionated heparin was associated with higher complication rates compared to sequential compression devices (RR = 3.10, p = 0.018) and low molecular weight heparin (RR = 2.79, p < 0.001) for DVT prophylaxis. No other perioperative blood thinner regimens were significantly associated with postoperative complications. Most regimens, including baseline blood thinners, aspirin flap prophylaxis, and DVT prophylaxis, can be managed safely in the perioperative period. However, unfractionated heparin was associated with higher complication rates than other DVT prophylaxis regimens. While baseline blood thinners did not increase most complications, prolonged preoperative holding and delayed resumption may jeopardize flap viability-highlighting a modifiable point of intervention.

Subunit-Based Intraflap Debulking Technique for Secondary Contouring After Free Flap Reconstruction.

Soft-tissue reconstruction of the distal leg, ankle, and foot remains challenging due to limited local tissue and compromised vascularity. Propeller perforator flaps have emerged over the past 2 decades as an alternative to free flaps, offering preservation of major vascular axes and reduced donor-site morbidity. However, clinical outcomes remain heterogeneous, and the reliability and functional benefits of PPFs are still debated. A PRISMA-2020-compliant systematic review (PROSPERO: CRD420251148124) was conducted through August 2025 across PubMed, MEDLINE, Embase, Ovid, and Web of Science. Eligible studies included observational designs, case series, and case reports on PPFs for lower-extremity reconstruction. Primary outcomes included flap survival, necrosis, venous congestion, infection, reoperation, functional recovery, and quality of life. The risk of bias was assessed using the Joanna Briggs Institute tools and the Newcastle-Ottawa Scale. Fifty-one studies (n = 1474 patients) met the inclusion. Trauma was the leading etiology (88%), with reconstructions most often involving the ankle/malleolar and heel regions. Posterior tibial and peroneal artery perforators were used in 74% of cases. Complete flap survival was reported in 47% of studies; partial necrosis in 28%, and total flap loss in 10%. Venous congestion was common but often self-limiting. Functional outcomes were inconsistently reported and generally favorable in fewer than half of the studies. Methodological quality was moderate to good in most reports. Propeller perforator flaps are a feasible reconstructive option for lower limb defects, although outcomes remain variable. Further prospective, comparative studies are needed to establish their long-term reliability and functional impact.

Dental rehabilitation has a significant impact on health-related quality of life (HRQOL) for patients undergoing microvascular reconstruction of the jaw. Virtual surgical planning (VSP) and computer-aided design and computer-aided manufacturing (CAD/CAM) technology allows for precise and timely delivery of an implant-retained dental prosthesis. This study characterizes the cost to produce a point of care (in-house) 3D-printed resin dental prostheses for patients undergoing osseous free flap reconstruction. Implant-retained dental prostheses for patients undergoing osseous free flap reconstruction of the maxilla or mandible produced by the Integrated Prosthetics and Reconstruction (IPR) laboratory at Chris O'Brien Lifehouse Hospital between July 2023 and June 2024 were analysed. The costs of producing the prostheses were calculated using a "bottom up" approach where all activities associated with start-up, planning and fabrication were accounted for and unit costs for each activity quantified. Prostheses with incomplete data were excluded. All costs are reported in 2024 as USD. Twenty-one patients met the study inclusion criteria of which the majority (n = 19) underwent mandibular reconstruction. Twelve patients underwent reconstruction for benign disease and 17 patients had the prosthesis placed at the primary reconstruction. The mean cost of producing the dental prosthesis was $861.72 (range: $702.78 - $1032.34). Start-up costs were the highest contributor (mean cost $333.71) per prosthesis, followed by the design/planning phase (mean cost $260.37), and fabrication phase (mean cost $267.64). The overall cost increased with increasing number of implant fixtures and the number of prosthetic units placed. VSP and CAD/CAM technology allows for rapid and accessible dental rehabilitation following osseous free flap reconstruction. However, the significant startup costs of these technologies are likely to be a barrier to institutions wanting to introduce point-of-care manufacturing of dental prosthetics.

This study aimed to compare donor-site morbidity among three common major lower extremity free flaps: fibula (FFF), anterolateral thigh (ALT), and the medial sural perforator (MSAP) using an established patient-reported outcome measure (PROM), the Lower Extremity Functional Scale (LEFS). Patients who underwent head and neck reconstruction with either FFF, MSAP, or ALT were included. The primary outcome was functional recovery, assessed using the modified LEFS, a PROM measuring functional status, administered at multiple post-operative timepoints. Seventy-five patients were included in the analysis: 33 FFF, 22 MSAP and 20 ALT. Patients undergoing lower extremity free flap surgery overall recovered well. The LEFS scores at different time points demonstrated quicker recovery for the MSAP group, while ALT and FFF recovered later. After 360 days, the MSAP group also demonstrated improved functional outcomes compared to the ALT and FFF. Patients undergoing lower extremity free flap surgery recover well. The MSAP had the least donor-site morbidity. Donor-site morbidity should be considered when counseling patients.

After studying this article, the participant should be able to: 1. Define the indications, benefits, and drawbacks of thigh-based flap donor sites for breast reconstruction. 2. Recognize the differences between popular thigh-based flaps and the utility of each. 3. Understand the anatomy of thigh-based free flaps, including their landmarks, vascular pedicles, and techniques of flap harvest. 4. Manage donor-site healing and complications. Thigh-based free flaps have become a popular flap option for autologous breast reconstruction. Critiques of thigh-based flaps include inadequate flap volume and donor-site concerns, such as poor appearance, sensory changes, and problematic healing; however, refinements in surgical technique have led to more predictable outcomes. The purpose of this article is to review the advantages and disadvantages of the various thigh-based free flaps for breast reconstruction, including gracilis myocutaneous, profunda artery perforator, and lateral thigh perforator flaps. Practical pearls for flap harvest and optimization of aesthetic results are provided.