Multi-pedicled Long Fasciocutaneous Free Flaps in Complex Lower Extremity Reconstruction

2021 ◽  
Author(s):  
Omar Abbassi ◽  
Frances Freer ◽  
Quillan “Q” Young Sing ◽  
Hidehiko Hoshimatsu ◽  
Ryo Karakawa ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Free Flaps ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction

Proximal versus Distal Recipient Vessels in Lower Extremity Reconstruction: A Retrospective Series and Systematic Review

2018 ◽  
Vol 34 (05) ◽  
pp. 334-340 ◽  
Author(s):  
Zachary Borab ◽  
William Rifkin ◽  
Adam Jacoby ◽  
Z-Hye Lee ◽  
Lavinia Anzai ◽  
...  
Keyword(s):  
Systematic Review ◽  
Lower Extremity ◽  
Free Flaps ◽  
Pooled Analysis ◽  
Perioperative Outcomes ◽  
Complication Rates ◽  
Recipient Vessel ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
The Impact

Background Recipient vessels proximal to the zone of injury have traditionally been preferred for lower extremity reconstruction. However, more recent data have shown mixed outcomes when performing anastomoses distal to the zone of injury. We investigated the impact of recipient vessel location on free flap outcomes. Methods Retrospective review (1979–2016); 312 soft tissue free flaps for open tibia fractures met inclusion criteria. Flap characteristics and perioperative outcomes were examined. Systematic review identified articles evaluating anastomosis location and flap outcomes; pooled data analysis was performed. Results More anastomoses were performed proximal to the zone of injury (80.7%) than distal (19.3%). Distal anastomoses were not associated with increased take back rates (19.6%) compared with proximal (23.8%) anastomoses (p = 0.356). Regression analysis comparing proximal and distal anastomoses found no difference in partial flap failures (7.4% vs 11.9%; p = 0.978) or total flap failures (9.3% vs 9.3%; p = 0.815) when controlling for the presence of arterial injury, flap type, and time from injury to coverage. Systematic review yielded 11 articles with 1,245 proximal and 127 distal anastomoses for comparison. Pooled analysis (p = 0.58) and weighted comparative analysis (p = 0.39) found no difference in flap failure rates between proximal and distal groups. Conclusion Our results are congruent with the current lower extremity literature and demonstrate no difference in perioperative complication rates between anastomoses performed proximal or distal to the zone of injury. These findings suggest that anastomotic location choice should be based primarily on recipient vessel quality/flow and ease of access/exposure rather than orientation relative to the zone of injury.

Importance of Vascularity and Selecting the Recipient Vessels of Lower Extremity Reconstruction

2020 ◽  
Author(s):  
Joon Pio Hong ◽  
Changsik John Park ◽  
Hyunsuk Peter Suh
Keyword(s):  
Decision Making ◽  
Lower Extremity ◽  
Free Flaps ◽  
Recipient Vessel ◽  
Multiple Factors ◽  
Surrounding Environment ◽  
The Status ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction

Abstract Background Successful lower extremity reconstruction using free flaps begins by identifying a good recipient vessel and understanding the surrounding environment of the defect. Methods One should consider multiple factors when selecting the recipient vessel such as the status of the axial arteries, trying to preserve flow as much as possible, extent and severity of the defect, and ultimately what type of anastomosis will be ideal. Results Multiple factors of importance are reviewed and show the relevance in decision making and provide an algorithm. Conclusion In addition to the multiple factors to be considered, the ultimate decision should be made on the table during surgery when the actual artery or vein is exposed and shows signs of good pulsation and flow.

scholarly journals Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction

2020 ◽  
Vol 34 (03) ◽  
pp. 200-206
Author(s):  
Mohamed A. Ellabban ◽  
Ahmed I. Awad ◽  
Geoffrey G. Hallock
Keyword(s):  
Lower Extremity ◽  
Donor Site ◽  
Free Flaps ◽  
Donor Site Morbidity ◽  
Peripheral Vascular ◽  
Perforator Flaps ◽  
Vascular Insufficiency ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
Bone Exposure

AbstractReconstruction of the lower extremity is considered a major challenge due to frequent bone exposure and the absence of local tissue redundancy, as well as often due to the presence of vascular insufficiency. Many surgeons have preferred free flaps especially for reconstructing the more distal lower limb defects until the evolution of pedicled perforator flaps and propeller flaps in particular provided a like-with-like reconstruction of the lower extremity without affecting the main vessels of the limb or the underlying muscles, and without the risk of any microanastomosis especially in patients with multiple comorbidities. Perforator-pedicled propeller flaps as local flaps in the lower extremity are best suited for small- and medium-sized defects with minimal donor-site morbidity, regardless of the cause of the defect. Any of the three source vessels of the leg can provide reliable perforators for propeller flap coverage of the distal leg and foot. The three main risk factors that are relative contraindications may be advanced age, diabetes mellitus, and atherosclerotic peripheral vascular disease.

Vein Grafting in Microsurgical Lower Extremity Reconstruction: Outcome Analysis of Primary versus Secondary Salvage Procedures

2021 ◽  
Author(s):  
Emre Gazyakan ◽  
Lingyun Xiong ◽  
Jiaming Sun ◽  
Ulrich Kneser ◽  
Christoph Hirche
Keyword(s):  
Lower Extremity ◽  
Free Flap ◽  
Free Flaps ◽  
Matched Pair ◽  
Complication Rates ◽  
Matched Pair Analysis ◽  
Flap Loss ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction ◽  
Pair Analysis

Abstract Objective Many microsurgeons fear high complication rates and free flap loss when vein grafting is necessary to restore blood flow at the recipient site. The aims of this study were to comparatively analyze surgical outcomes of interposition vein grafts (VG) in microsurgical primary lower extremity reconstruction and secondary salvage procedures. Patients and Methods A retrospective study was conducted on 58 patients undergoing free flap transfers with vein grafting for primary lower extremity reconstruction (cohort 1) and secondary salvage procedures (cohort 2) between 2002 and 2016. A matched-pair analysis of both cohorts and 58 non-VG flaps was performed. Patient data, preoperative conditions, flap and vein graft characteristics, postoperative outcomes such as flap failure, thrombosis, and wound complications were analyzed. Results A total of 726 free flap transfers were performed. In total, 36 primary reconstructions (5%) utilized 41 interposition VG (cohort 1). Postoperative vascular compromise was observed in 65 free flaps (9%). In total, 22 out of 65 secondary salvage procedures (33.8%) utilized 26 interposition VG (cohort 2). Two total flap losses occurred in each cohort (5.6 vs. 9.1%; p = 0.63). Postoperative complications were observed in 38.9% of free flaps in cohort 1 and 72.7% in cohort 2 (p = 0.01). Takeback for microvascular compromise was comparable in both cohorts (19.4 vs. 22.7%; p = 0.75). Microvascular complications occurred more often in cohort 2 (22.7%) than in cohort 1 (8.3%; p = 0.28). Lower extremity salvage rates were high among both cohorts (94.4 vs. 90.9%; p = 0.63). Matched-pair analysis did not show any relevant differences on takebacks and flap loss (p = 0.32 and p = 1.0). Conclusion In complex lower extremity reconstructions, VG can be performed with acceptable complication rates and outcomes in primary and especially in salvage cases. With careful planning and a consistent surgical protocol, VG can provide reliable success rates in limb salvage.

Comparison of Hand-Sewn versus Coupled Venous Anastomoses in Traumatic Lower Extremity Reconstruction

2018 ◽  
Vol 35 (01) ◽  
pp. 031-036 ◽  
Author(s):  
William Rifkin ◽  
Z-Hye Lee ◽  
Lavinia Anzai ◽  
Adam Jacoby ◽  
Daniel Ceradini ◽  
...  
Keyword(s):  
Lower Extremity ◽  
Free Flaps ◽  
Perioperative Outcomes ◽  
Microvascular Reconstruction ◽  
Failure Rates ◽  
Venous Anastomosis ◽  
Flap Failure ◽  
Type Iiib ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction

Background Microvascular reconstruction of the lower extremity has the highest reported complication and flap failure rates of any anatomical region. Despite widespread adoption of the mechanical anastomotic venous coupler and encouraging results in other anatomical regions, there are limited reports examining its use in the lower extremity. This study compares outcomes between coupled and hand-sewn venous anastomoses in traumatic lower extremity reconstruction. Methods Retrospective review of our institutional flap registry from 1979 to 2016 identified soft tissue free flaps performed for the reconstruction of Gustilo type IIIB/IIIC open tibial fractures. Patient demographics, flap characteristics, use of a venous anastomotic coupler, and perioperative outcomes were examined. Analysis was performed using chi-square and Student's t-tests. Results A total of 361 patients received a microvascular free flap for coverage of a Gustilo type IIIB or IIIC tibial fracture following traumatic injury. After excluding cases that lacked adequate information on coupler use, 358 free flaps were included in the study. There were 72 (20%) free flaps performed using a venous coupler and 286 (80%) performed with hand-sewn venous anastomoses. There were comparable rates of major complications (22.2 vs. 26.1%; p = 0.522), total flap failure (6.5%, vs. 10.2%; p = 0.362), and partial flap failure (9.7 vs. 12.2%; p = 0.579) between venous coupler and hand-sewn anastomoses, respectively. Furthermore, use of the venous coupler was not associated with increased rates of operative take backs (22.8 vs. 23.0%; p = 0.974). However, reconstructions performed using a venous coupler were significantly more likely to have a second venous anastomosis performed (37.5 vs. 21.3%; p = 0.004). Conclusion Complication and flap failure rates were similar between reconstructions performed with a venous coupler and those performed with hand-sewn venous anastomoses. These findings suggest that use of the venous anastomotic coupler is safe and effective in lower extremity reconstruction, with comparable outcomes to conventional sutured anastomoses.

Preserving the Blood Flow of the Recipient Artery in Cross-Leg Free Flap Procedure for Lower Extremity Reconstruction

2020 ◽  
Vol 19 (3) ◽  
pp. 255-261 ◽  
Author(s):  
Zulfukar Ulas Bali ◽  
Berrak Karatan ◽  
Yavuz Tuluy ◽  
Yavuz Kececi ◽  
Levent Yoleri
Keyword(s):  
Blood Flow ◽  
Lower Extremity ◽  
Free Flaps ◽  
Posterior Tibial Artery ◽  
Anterolateral Thigh Flap ◽  
Recipient Artery ◽  
Anterolateral Thigh ◽  
Thoracodorsal Artery ◽  
Lower Extremity Reconstruction ◽  
Extremity Reconstruction

When there is no suitable vessel in the injured leg for microsurgical transfer, cross-leg free flaps can be considered for lower extremity reconstruction. This report describes patients who experienced lower extremity trauma and underwent reconstruction with cross-leg free flaps with preserved blood flow in the recipient artery. Anterolateral thigh flap is preferred for small to moderate defects. The descending branch of the lateral femoral circumflex artery was dissected 2 cm proximally and distally and was prepared in a T-shape. The branches of the T were anastomosed to the recipient artery in the contralateral leg in the first session of the cross-leg free flap procedure. After 3 weeks, the flap artery was separated from the bifurcation. For large defects, the latissimus dorsi flap was chosen. The thoracodorsal artery was anastomosed to the contralateral posterior tibial artery in the first session. After 3 weeks, to provide recipient vessel integrity, the thoracodorsal artery was transected from the flap and anastomosed to the distal stump of the posterior tibial artery. Between January 2017 and January 2019, 8 defects were reconstructed using an anterolateral thigh flap; the remaining 4 defects were reconstructed using a latissimus dorsi flap. All flaps survived without complications. Anterograde flow distal to the anastomosis was confirmed in all recipient arteries via Doppler ultrasound. In cross-leg free flaps, the continuity of the recipient artery can be established to prevent diminished blood flow to the recipient extremity.

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