{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T19:22:15Z","timestamp":1787167335226,"version":"build-2736575974"},"reference-count":47,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2020,2,21]],"date-time":"2020-02-21T00:00:00Z","timestamp":1582243200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>The nutritional condition of patients is an important prognostic factor in various diseases. Free flap failure is a serious complication in patients undergoing free flap reconstruction, increasing morbidity and hospital costs. We evaluated the predictive factors, including the prognostic nutritional index (PNI), associated with free flap failure in extremity reconstruction. The PNI was calculated as follows: 10 \u00d7 serum albumin (g\/dL) + 0.005 \u00d7 total lymphocyte count (per mm3), with a PNI &lt;40 defined as low. Univariate and multivariate logistic regression analyses were performed to evaluate factors predictive of free flap failure. Postoperative outcomes, including duration of hospital stay and rate and duration of intensive care unit admission, were also evaluated. Of the 625 patients included, 38 (6.1%) experienced free flap failure. Multivariate logistic regression analysis revealed that predictors of free flap failure were female (odds ratio: 2.094; p = 0.031) and a low PNI (odds ratio: 3.859; p &lt;0.001). The duration of hospital stay was significantly longer in patients who did than those who did not experience free flap failure (62.1 \u00b1 55.5 days vs. 28.3 \u00b1 24.4 days, p &lt;0.001). A low PNI is associated with free flap failure, leading to prolonged hospital stay. This result suggests that the PNI can be simply and effectively used to predict free flap failure.<\/jats:p>","DOI":"10.3390\/nu12020562","type":"journal-article","created":{"date-parts":[[2020,2,21]],"date-time":"2020-02-21T08:59:47Z","timestamp":1582275587000},"page":"562","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":35,"title":["Prognostic Nutritional Index is a Predictor of Free Flap Failure in Extremity Reconstruction"],"prefix":"10.3390","volume":"12","author":[{"given":"Jihion","family":"Yu","sequence":"first","affiliation":[{"name":"Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joon Pio","family":"Hong","sequence":"additional","affiliation":[{"name":"Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hyunsuk Peter","family":"Suh","sequence":"additional","affiliation":[{"name":"Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4476-4945","authenticated-orcid":false,"given":"Jun-Young","family":"Park","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Doo-Hwan","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Seungsoo","family":"Ha","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joonho","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jai-Hyun","family":"Hwang","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1982-3053","authenticated-orcid":false,"given":"Young-Kug","family":"Kim","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,2,21]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"737","DOI":"10.1097\/PRS.0b013e3181b17a56","article-title":"Perforator flaps: Recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions","volume":"124","author":"Massey","year":"2009","journal-title":"Plast Reconstr. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"177","DOI":"10.1097\/PRS.0b013e3181c49580","article-title":"Advancements in free flap monitoring in the last decade: A critical review","volume":"125","author":"Smit","year":"2010","journal-title":"Plast Reconstr. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1002\/micr.22223","article-title":"Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database","volume":"35","author":"Wong","year":"2015","journal-title":"Microsurgery"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1956","DOI":"10.1097\/SCS.0000000000003026","article-title":"Risk factors leading to free flap failure: Analysis from the national surgical quality improvement program database","volume":"27","author":"Massenburg","year":"2016","journal-title":"J. Craniofac. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1080","DOI":"10.1097\/SCS.0b013e3181763531","article-title":"Diabetes as main risk factor in head and neck reconstructive surgery with free flaps","volume":"19","author":"Valentini","year":"2008","journal-title":"J. Craniofac. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1097\/00006534-200007000-00012","article-title":"Factors affecting outcome in free-tissue transfer in the elderly","volume":"106","author":"Serletti","year":"2000","journal-title":"Plast Reconstr. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1345","DOI":"10.1002\/hed.21331","article-title":"Clinicopathologic and therapeutic risk factors for perioperative complications and prolonged hospital stay in free flap reconstruction of the head and neck","volume":"32","author":"Patel","year":"2010","journal-title":"Head Neck"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"61","DOI":"10.1177\/0884533609358997","article-title":"Understanding the role of nutrition and wound healing","volume":"25","author":"Stechmiller","year":"2010","journal-title":"Nutr. Clin. Pract."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"2375","DOI":"10.1002\/1097-0142(19810515)47:10<2375::AID-CNCR2820471009>3.0.CO;2-I","article-title":"The efficacy of nutritional assessment and support in cancer surgery","volume":"47","author":"Smale","year":"1981","journal-title":"Cancer"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"169","DOI":"10.1016\/j.joms.2013.05.022","article-title":"Low prealbumin level is a risk factor for microvascular free flap failure","volume":"72","author":"Shum","year":"2014","journal-title":"J. Oral Maxillofac. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"491","DOI":"10.1055\/s-0034-1369807","article-title":"A new plane of elevation: The superficial fascial plane for perforator flap elevation","volume":"30","author":"Hong","year":"2014","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"592","DOI":"10.1097\/PRS.0000000000000951","article-title":"The search for the ideal thin skin flap: Superficial circumflex iliac artery perforator flap--a review of 210 cases","volume":"135","author":"Goh","year":"2015","journal-title":"Plast Reconstr. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"738","DOI":"10.1097\/PRS.0000000000003147","article-title":"Study of the medial superficial perforator of the superficial circumflex iliac artery perforator flap using computed tomographic angiography and surgical anatomy in 142 patients","volume":"139","author":"Suh","year":"2017","journal-title":"Plast Reconstr. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1354","DOI":"10.1002\/hed.21105","article-title":"Analysis of free flap viability based on recipient vein selection","volume":"31","author":"Francis","year":"2009","journal-title":"Head Neck"},{"key":"ref_15","first-page":"1001","article-title":"Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients","volume":"85","author":"Onodera","year":"1984","journal-title":"Nihon Geka Gakkai Zasshi"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1002\/jso.25140","article-title":"Preoperative prognostic nutritional index predicts survival of patients with intrahepatic cholangiocarcinoma after curative resection","volume":"118","author":"Akgul","year":"2018","journal-title":"J. Surg. Oncol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1217","DOI":"10.1007\/s00268-013-2386-x","article-title":"Low nutritional prognostic index correlates with poor survival in patients with stage iv colorectal cancer following palliative resection of the primary tumor","volume":"38","author":"Maeda","year":"2014","journal-title":"World J. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"708","DOI":"10.1097\/00006534-197612000-00010","article-title":"Replantations and free flap transfers by microvascular surgery","volume":"58","author":"Ohtsuka","year":"1976","journal-title":"Plast Reconstr. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"396","DOI":"10.1002\/micr.1920160609","article-title":"Free flap failures","volume":"16","author":"Suominen","year":"1995","journal-title":"Microsurgery"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1097\/PRS.0b013e3181da8812","article-title":"Unilateral failures in bilateral microvascular breast reconstruction","volume":"126","author":"Rao","year":"2010","journal-title":"Plast Reconstr. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"259","DOI":"10.1097\/00006534-199108000-00014","article-title":"Microsurgical free-tissue transfer in the elderly patient","volume":"88","author":"Shestak","year":"1991","journal-title":"Plast Reconstr. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1026","DOI":"10.3945\/ajcn.115.126615","article-title":"Undernutrition screening survey in 564,063 patients: Patients with a positive undernutrition screening score stay in hospital 1.4 d longer","volume":"103","author":"Kruizenga","year":"2016","journal-title":"Am. J. Clin. Nutr."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2177","DOI":"10.1373\/clinchem.2006.077412","article-title":"Serum prealbumin: Is it a marker of nutritional status or of risk of malnutrition?","volume":"52","author":"Shenkin","year":"2006","journal-title":"Clin. Chem."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1439","DOI":"10.1038\/bjc.2012.92","article-title":"A novel, externally validated inflammation-based prognostic algorithm in hepatocellular carcinoma: The prognostic nutritional index (PNI)","volume":"106","author":"Pinato","year":"2012","journal-title":"Br. J. Cancer"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1097\/SLA.0b013e3181e9819a","article-title":"Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: A multi-institutional study","volume":"252","author":"Hennessey","year":"2010","journal-title":"Ann. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"308","DOI":"10.1002\/bjs.1800690604","article-title":"The effects of subclinical malnutrition and refeeding on the healing of experimental colonic anastomoses","volume":"69","author":"Ward","year":"1982","journal-title":"Br. J. Surg."},{"key":"ref_27","first-page":"433","article-title":"The dehiscence of colorectal anastomoses: The risk factors","volume":"71","author":"Testini","year":"2000","journal-title":"Ann. Ital. Chir."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"493","DOI":"10.1016\/0008-8749(92)90088-7","article-title":"Impairment of macrophage activation and granuloma formation by protein deprivation in mice","volume":"139","author":"Reynolds","year":"1992","journal-title":"Cell. Immunol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"617","DOI":"10.1067\/msy.2001.112963","article-title":"Malnutrition-induced macrophage apoptosis","volume":"129","author":"Rivadeneira","year":"2001","journal-title":"Surgery"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"789","DOI":"10.1046\/j.1365-2044.1998.00438.x","article-title":"Serum albumin: Touchstone or totem?","volume":"53","author":"Margarson","year":"1998","journal-title":"Anaesthesia"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1343","DOI":"10.1016\/0016-5085(86)90185-X","article-title":"Low-protein-concentration ascitic fluid is predisposed to spontaneous bacterial peritonitis","volume":"91","author":"Runyon","year":"1986","journal-title":"Gastroenterology"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"313","DOI":"10.1146\/annurev.immunol.021908.132657","article-title":"Regulatory lymphocytes and intestinal inflammation","volume":"27","author":"Izcue","year":"2009","journal-title":"Annu. Rev. Immunol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"945","DOI":"10.7314\/APJCP.2014.15.2.945","article-title":"Neutrophil count and the inflammation-based glasgow prognostic score predict survival in patients with advanced gastric cancer receiving first-line chemotherapy","volume":"15","author":"Li","year":"2014","journal-title":"Asian Pac. J. Cancer Prev."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"321","DOI":"10.1245\/s10434-015-4614-0","article-title":"Preoperative prognostic nutritional index is a significant predictor of survival in renal cell carcinoma patients undergoing nephrectomy","volume":"23","author":"Jeon","year":"2016","journal-title":"Ann. Surg. Oncol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"525","DOI":"10.1245\/s10434-015-4814-7","article-title":"Predictive potential of preoperative nutritional status in long-term outcome projections for patients with gastric cancer","volume":"23","author":"Sakurai","year":"2016","journal-title":"Ann. Surg. Oncol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1537","DOI":"10.1007\/s00432-014-1714-3","article-title":"The prognostic significance of the prognostic nutritional index in cancer: A systematic review and meta-analysis","volume":"140","author":"Sun","year":"2014","journal-title":"J. Cancer Res. Clin. Oncol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"532","DOI":"10.1007\/s00595-011-0061-0","article-title":"The prognostic nutritional index can be a prognostic indicator in colorectal carcinoma","volume":"42","author":"Nozoe","year":"2012","journal-title":"Surg. Today"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2688","DOI":"10.1007\/s00268-013-2156-9","article-title":"Prognostic nutritional index predicts postoperative outcome in colorectal cancer","volume":"37","author":"Mohri","year":"2013","journal-title":"World J. Surg."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1002\/bjs.7305","article-title":"Nutritional predictors of postoperative outcome in pancreatic cancer","volume":"98","author":"Kanda","year":"2011","journal-title":"Br. J. Surg."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1681","DOI":"10.1016\/j.clnu.2016.10.021","article-title":"Pre-therapeutic nutritional assessment for predicting severe adverse events in patients with head and neck cancer treated by radiotherapy","volume":"36","author":"Kono","year":"2017","journal-title":"Clin. Nutr."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1505","DOI":"10.1161\/01.CIR.95.6.1505","article-title":"Estrogen-receptor-mediated inhibition of human endothelial cell apoptosis. Estradiol as a survival factor","volume":"95","author":"Spyridopoulos","year":"1997","journal-title":"Circulation"},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Tu, J., and Jufri, N.F. (2013). Estrogen signaling through estrogen receptor beta and g-protein-coupled estrogen receptor 1 in human cerebral vascular endothelial cells: Implications for cerebral aneurysms. Biomed. Res. Int., 2013.","DOI":"10.1155\/2013\/524324"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1002\/micr.30332","article-title":"Diabetes is not associated with increased rates of free flap failure: Analysis of outcomes in 6030 patients from the acs-nsqip database","volume":"39","author":"Kantar","year":"2019","journal-title":"Microsurgery"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"711","DOI":"10.1097\/00006534-199809010-00015","article-title":"A prospective study of microvascular free-flap surgery and outcome","volume":"102","author":"Khouri","year":"1998","journal-title":"Plast Reconstr. Surg."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1097\/01.prs.0000244745.21562.58","article-title":"Microvascular breast reconstruction in the diabetic patient","volume":"119","author":"Miller","year":"2007","journal-title":"Plast Reconstr. Surg."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1097\/PRS.0b013e318277856f","article-title":"Comprehensive outcome and cost analysis of free tissue transfer for breast reconstruction: An experience with 1303 flaps","volume":"131","author":"Fischer","year":"2013","journal-title":"Plast Reconstr. Surg."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1292","DOI":"10.1016\/j.jcms.2016.04.029","article-title":"Predictors of free flap loss in the head and neck region: A four-year retrospective study with 451 microvascular transplants at a single centre","volume":"44","author":"Mucke","year":"2016","journal-title":"J. Craniomaxillofac. Surg."}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/12\/2\/562\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T08:59:43Z","timestamp":1760173183000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/12\/2\/562"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,2,21]]},"references-count":47,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2020,2]]}},"alternative-id":["nu12020562"],"URL":"https:\/\/doi.org\/10.3390\/nu12020562","relation":{},"ISSN":["2072-6643"],"issn-type":[{"value":"2072-6643","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,2,21]]}}}