Understanding Risk in Emergent Reconstructive Flap Surgery.

Background: Flap-based reconstruction is critical for soft tissue defect coverage, but risks in emergency cases are poorly defined. This study compared postoperative outcomes of emergency versus elective myocutaneous and fasciocutaneous flap reconstructions. Methods: We conducted a retrospective cross-sectional study of adults undergoing flap reconstruction from 2012 to 2023 in the American College of Surgeons National Surgical Quality Improvement Program database. Patients were categorized as emergency or elective. Primary outcomes included 30-day mortality, major complications, surgical site infections, and overall complications. Multivariable logistic regression adjusted for demographics, comorbidities, nutritional status, and physiological markers. Results: Among 12,263 patients, 1570 (12.8%) had emergency reconstructions. Emergency patients more often presented with sepsis, anemia, functional dependence, and American Society of Anesthesiologists class III-V. Unadjusted analysis showed that emergency status was associated with higher rates of mortality (odds ratio [OR] 4.77, 95% confidence interval [CI] 3.01-7.55, P < 0.001), major complications (OR 2.44, 95% CI 1.78-3.35, P < 0.001), and any complication (OR 1.44, 95% CI 1.26-1.64, P < 0.001). Surgical site infection rates were lower (OR 0.83, 95% CI 0.70-1.00, P = 0.048) but not significant after adjustment. After risk adjustment, emergency status remained independently associated with increased mortality (adjusted OR 14.78, 95% CI 2.09-104.35, P = 0.007) and major complications (adjusted OR 3.21, 95% CI 1.25-8.24, P = 0.015) but not with surgical site infection or overall complication rate. Conclusions: Emergency flap reconstruction is independently linked to higher short-term mortality and major complications compared with elective cases, even after accounting for comorbidities and physiological status. These findings underscore the need for careful perioperative planning, triage, and risk mitigation strategies in urgent settings.