SLR - November 2020 - Kristy Iwahashi-Marquez

Safety and Effectiveness of Early Compression of Free Flaps Following Lower Limb Reconstruction: A Systematic Review

Reference: J.E. Berner, P. Will, L. Geoghegan, L. Troisi, J. Nanchahal, A. Jain. Safety and Effectiveness of Early Compression of Free Flaps Following Lower Limb Reconstruction: A systematic Review. J Plast Reconstr Aesthet Surg. 2020 June 17; 20(5), 1748-6815

Level of evidence: Level III

Scientific Literature Review

Reviewed By: Kristy Iwahashi-Marquez, DPM
Residency Program: DVA Southern Arizona Health Care System – Tucson, AZ

Podiatric Relevance: Limb salvage and wound care is a large component of podiatric medicine; however, it can be difficult and challenging to determine the most optimal choice for the patient. There are situations when a patient would benefit from reconstructive surgery, which may include free flaps to aid in closure. When utilizing a free flap, there is always the risk of flap failure. Caution must be taken with postoperative care of a flap to give the greatest chance of survival. The traditional thought that compression decreased flap perfusion resulting in failure has recently been questioned. Ideation of compression allowing decrease in edema while helping with venous return and lymphatic drainage are a few factors considered in the debate. Authors of this article sought to determine the safeness and effectiveness of early compression to free flaps for lower limb reconstruction with a systematic review. 

Methods: This systematic review used a combination of randomized and non-randomized controlled trials, cohort, case-control, case series and case report studies (Level of evidence: III). The PRISMA statement guidance was employed for the design of the review. Articles included were the study’s reported by outcome of lower limb reconstruction free flaps, and if the patient underwent compression of the free flap by any type of modality. Two independent authors screened and reviewed all publications, which met the inclusion and exclusion criteria. Cochrane risk of bias tool and National Institute of Health Quality Assessment tool were exercised for a formal risk of bias. 

Results: The final number of eligible articles included two randomized controlled trials, four retrospective cohort studies and four case series. All were published between 2008 and 2019. Within these reports, there were a total of 262 flaps that have undergone some remedy of compression. Median age was 54 years-old, with a range of 6-88 years of age. Early flap compression was distinguished as intervention within the first week postoperatively. Seven early flap compression studies, which consisted of 253 patients (all using elastic bandages), reported four flap failures (1.6 percent). The remaining three performed compression between 14 and 28 postoperative days resulting in no flap failures. There were also reports of decreased edema and reduction of pain. Bias assessments for articles included in this review were moderate and low. 

Conclusions: The authors concluded that according to their review, compression of free flaps is not associated with a higher failure rate for free flaps. The results of this study were limited due to the quality of eligible publications. There were no standardized controlled groups, application of bandages is operator dependent, and other factors that may affect pedicle blood flow were not considered; for example, hypercoagulability state. Overall, this review was commendable for insight to help further pursue a consensus of early compression for lower extremity free flaps. Nonetheless, further studies should be performed for better quality results, perhaps by including a standardized control group.  

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