title: Free tissue transfer to the lower extremity distal to the zone of injury: indications and outcomes over a 25-year experience.
abstract: BACKGROUND
  Microvascular free flap anastomoses performed for lower extremity reconstruction are traditionally proximal to the zone of injury. The authors assessed the feasibility and outcomes of microvascular free flaps with anastomoses performed distal to the zone of injury.
  
  
  METHODS
  The authors retrospectively reviewed all microvascular free flaps performed at their institution over the past 10 years for lower extremity reconstruction and compared this group with their previously published experience (January of 1979 through August of 1995). Between September of 1995 and May of 2005, 119 flap procedures were performed for lower extremity reconstruction. Twenty-eight flaps (24 percent) were anastomosed distal to the zone of injury and 87 (76 percent) were anastomosed proximally. There were insufficient data on the location of the anastomosis for four free flaps (all successful).
  
  
  RESULTS
  Twenty-seven of 28 distal microvascular free flaps were successful (96 percent); two (7 percent) required emergent postoperative reexploration of the anastomosis. Of the 87 proximal flaps, 79 (91 percent) were successful and eight (9 percent) failed. There was no statistically significant difference in the success rate of microvascular free flaps between the proximal and distal anastomosis groups (p = 0.30, Fisher's exact test). Combined with the data from the authors' previous series (January of 1979 to August of 1995), there were 63 free flaps with anastomosis performed distal to the zone of injury; 61 (97 percent) were successful.
  
  
  CONCLUSIONS
  The authors' extensive 25-year experience with lower extremity reconstruction demonstrates that in appropriately selected patients, free tissue transfer to recipient vessels distal to the zone of injury is reliable and in certain cases preferable.
authors.affiliation: New York, N.Y. From the Division of Plastic Surgery, Weill Cornell Medical College, and Institute of Reconstructive Plastic Surgery, Division of Plastic Surgery, New York University School of Medicine.
authors.forename: Jason A
authors.initials: JA
authors.lastname: Spector
authors.forename: Steven
authors.initials: S
authors.lastname: Levine
authors.forename: Jamie P
authors.initials: JP
authors.lastname: Levine
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical; D005260:Female; D005268:Femoral Vein / Q000601:surgery; D005500:Follow-Up Studies; D006801:Humans; D007869:Leg Injuries / Q000601:surgery*; D008297:Male; D008833:Microcirculation; D008875:Middle Aged; D018482:Muscle, Skeletal / Q000098:blood supply / Q000637:transplantation*; D011150:Popliteal Artery / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000098:blood supply*; D013997:Time Factors; D016896:Treatment Outcome