Muscle Free Tissue Transfer May Be Superior To Fasciocutaneous Free Tissue Transfer In Lower Extremities With Venous Disease

PURPOSE: In extremities with high outflow venous pressures or venous reflex (VR), there are no studies to suggest preferred free flap (FF) choice. Our study aims to compare the use of fasciocutaneous (FCFF) versus muscle free flaps (MFF) in patients with VR and evaluate the postoperative outcomes for those with venous disease. METHODS: A retrospective review of 114 patients with presence of VR on preoperative LE venous duplex US imaging were included. 69 (60.5%) patients underwent FCFF and 45 (39.5%) patients underwent MFF. Demographics, comorbidities, venous findings, and outcomes were collected. RESULTS: Patients with MFF had a higher prevalence of diabetes (77.8% vs 53.6%, p<0.001), chronic kidney disease (33.3% vs. 11.6%, p=0.005), and end stage renal disease (15.6% vs. 2.9%, p=0.028). Between MFF and FCFF cohorts preoperatively, there were no significant differences in vessel run-off (VRO) on angiogram or VR on venous testing. Outcomes showed FCFF had higher rates of takeback (4.35% vs. 0.0%, p=0.156) and partial necrosis (5.8% vs. 0.0%, p=0.152). When stratifying patients by diseased vasculature, in 58 patients with venous disease only, FCFF had a higher rate of flap complications (17.7% vs. 0.0%, p=0.037). In 53 patients with both venous and arterial disease, FCFF had higher rates of takeback (9.1% vs. 0.0%, p=0.282), and partial flap necrosis (9.1% vs. 0.0%, p=0.282). CONCLUSION: There may be a benefit in using MFF over FCFF for highly comorbid patients with venous disease, which theoretically could be due to higher flow mechanics in muscle to overcome higher backpressures for refluxed vessels.