A Systematic Review of Outcomes and Flap Selection Following Lower Extremity Free Tissue Transfer Versus Vascularized Perforator Pedicle Flap Transfer in Lower Limb Reconstruction

Abstract Background Lower extremity defects often require free tissue transfer due to a paucity of local donor sites. Locoregional perforator-based flaps offer durable, single-stage reconstruction while avoiding the pitfalls of microsurgery. Multiple harvest techniques are described, yet few studies provide outcome comparisons. Specifically, no study has examined the impact of perforator flap pedicle skeletonization on reconstructive outcomes. This systematic review characterizes technique and impact of pedicle skeletonization on perforator-based fasciocutaneous flaps of the lower extremity. Methods PubMed, Scopus, and the Cochrane Central Register of Controlled Trials were reviewed for literature examining perforator-based fasciocutaneous flaps from knee to ankle, from January 2000 through November 2018. The Preferred Reporting Items for Systematic Reviews-Individual Participant Data (PRISMA-IPD) structure was used. Results Thirty-six articles were included for quantitative analysis. Of 586 flaps, 365 were skeletonized (60.1%) with 58 major (9.9%) and 19 minor complications (3.2%). With skeletonization, overall reoperative rate was higher (odds ratio [OR]: 9.71, p = 0.004), specifically in propeller (OR: 12.50, p = 0.004) and rotational flaps (OR: 18.87, p = 0.004). The complication rate of rotational flaps also increased (OR: 2.60, p = 0.04). Notably, skeletonization reduced complications in flaps rotated 90 degrees or more (OR: 0.21, p = 0.02). Reoperative rate of distal third defects (OR: 14.08, p = 0.02), flaps over 48 cm2 (OR: 33.33, p = 0.01), and length to width ratios over 1.75 (OR: 7.52, p = 0.03) was increased with skeletonization. Skeletonization increased complications in traumatic defects (OR: 2.87, p = 0.04) and reduced complications in malignant defects (OR: 0.10, p = 0.01). Conclusion Pedicled, perforator-based flaps can provide a reliable locoregional alternative to free tissue transfer for lower extremity defects. Though skeletonization increased the overall reoperative rate, the complication rate for flaps with 90 degrees or more of rotation was significantly reduced. This suggests skeletonization should be considered when large rotational movements are anticipated to reduce complications that can arise from pedicle compression and venous congestion.

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Safety and effectiveness of early compression of free flaps following lower limb reconstruction: A systematic review

Journal of Plastic Reconstructive & Aesthetic Surgery ◽

10.1016/j.bjps.2020.05.011 ◽

2020 ◽

Vol 73 (9) ◽

pp. 1604-1611

Author(s):

Juan Enrique Berner ◽

Patrick Will ◽

Luke Geoghegan ◽

Luigi Troisi ◽

Jagdeep Nanchahal ◽

...

Keyword(s):

Systematic Review ◽

Lower Limb ◽

Free Flaps ◽

Limb Reconstruction ◽

Lower Limb Reconstruction

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What Is Safe Limit of the Perforator Flap in Lower Extremity Reconstruction? Do We Have Answers Yet?

Plastic Surgery International ◽

10.1155/2011/349357 ◽

2011 ◽

Vol 2011 ◽

pp. 1-7 ◽

Cited By ~ 2

Author(s):

Nikhil S. Panse ◽

Yogesh C. Bhatt ◽

Mangesh S. Tandale

Keyword(s):

Lower Extremity ◽

Lower Limb ◽

Odds Ratio ◽

Perforator Flap ◽

Limb Length ◽

Limb Reconstruction ◽

Lower Limb Reconstruction ◽

Lower Extremity Reconstruction ◽

Extremity Reconstruction ◽

Safe Limit

We make an attempt to define the safe extent of local perforator flap for lower limb reconstruction by comparing it with the limb length of the patient. The maximum flap length from the perforator was compared to the limb length in 35 patients using EPI info 6.04 D software. On comparison of flaps that were less than one-third of limb length to those which were more than one-third of limb length, the statistical values were significant. The odds ratio calculated was 6, which means that there is a six times more chance that a local perforator flap will necrose if it is more than one-third of the limb length as compared to a flap which is less than one-third of the limb length.

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Thin Perforator Flaps for Reconstruction of the Lower Extremity

Journal of Reconstructive Microsurgery ◽

10.1055/s-0039-1695740 ◽

2019 ◽

Author(s):

Peggy J. Ebner ◽

Daniel J. Gould ◽

Ketan M. Patel

Keyword(s):

Lower Limb ◽

Lower Leg ◽

Soft Tissue Coverage ◽

Patient Centered ◽

Perforator Flaps ◽

Limb Reconstruction ◽

Flap Survival ◽

Flap Transfer ◽

Viable Solution ◽

Lower Limb Reconstruction

AbstractThin flaps, a modification of traditional flaps that minimize the need for debulking and revision, offer unique advantages in the field of lower limb reconstruction. Advances in the field of microsurgery have made this streamlined method of reconstruction a viable solution for soft tissue coverage in patients with both trauma and nonhealing wounds. Better understanding of anatomy has allowed for flap harvest above the fascia level and the Scarpal plane. These modifications allow for flap transfer with thicknesses more comparable to the native anatomy of the lower leg, ankle, and foot. Flap survival is comparable to traditional techniques with greater potential for improved patient-centered outcomes.

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A Systematic Review of Free Tissue Transfer in the Management of Non-traumatic Lower Extremity Wounds in Patients with Diabetes

European Journal of Vascular and Endovascular Surgery ◽

10.1016/j.ejvs.2010.11.013 ◽

2011 ◽

Vol 41 (3) ◽

pp. 391-399 ◽

Cited By ~ 42

Author(s):

E.J. Fitzgerald O’Connor ◽

M. Vesely ◽

P.J. Holt ◽

K.G. Jones ◽

M.M. Thompson ◽

...

Keyword(s):

Systematic Review ◽

Lower Extremity ◽

Free Tissue Transfer ◽

Tissue Transfer ◽

Patients With Diabetes

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Postoperative Management of Lower Extremity Free Tissue Transfer: A Systematic Review

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1667049 ◽

2018 ◽

Vol 35 (01) ◽

pp. 001-007 ◽

Cited By ~ 3

Author(s):

Carol Soteropulos ◽

Jenny Chen ◽

Samuel Poore ◽

Catharine Garland

Keyword(s):

Systematic Review ◽

Lower Extremity ◽

Weight Bearing ◽

Free Tissue Transfer ◽

Postoperative Management ◽

Venous Congestion ◽

Evidence Based ◽

Flap Survival ◽

Randomized Controlled ◽

Tissue Transfer

Background Free tissue transfer for lower extremity reconstruction is a safe and reliable option for a wide range of challenging wounds; however, no consensus exists regarding postoperative management. Methods A systematic review of postoperative management of lower extremity free tissue transfer was conducted using Medline, Cochrane Database, and Web of Science. Multicenter surveys, randomized controlled trials, cohort studies, and case series were reviewed. Results Fifteen articles investigating current protocols, flap physiology, and aggressive dangle protocols were reviewed. The following evidence-based conclusions were made: (1) Free tissue transfer to the lower extremity is unique due to altered hemodynamics and dependency during orthostasis. Free flap circulation is dependent on locally mediated responses and deprived of compensatory muscular and neurovascular mechanisms that prevent venous congestion in the normal extremity. (2) Compressive wrapping reduces venous congestion and edema and may induce ischemic conditioning, which can increase blood flow. (3) Dangle protocols vary widely in timing of initiation, frequency, and monitoring. Small volume studies examining aggressive mobilization protocols initiating early dependency have led to earlier ambulation and discharge, with no change in flap survival as compared with conservative protocols. (4) Weight bearing may begin after the completion of dangle protocol if no orthopedic injury is present. Conclusions Early initiation of a dangle protocol does not appear to negatively impact flap survival based on this systematic review. Compressive wrapping may be a useful adjunct. Many surgeons agree that clinical monitoring is sufficient; there is no consensus on the utility of adjunct monitoring techniques. Weight bearing may begin after completion of dangle protocol with close flap monitoring, if not prevented by orthopedic restrictions. By providing additional outflow vasculature to reduce venous congestion, flow-through anastomoses may eliminate the need for a dangle protocol. Further research, including large randomized controlled trials is still needed to establish high-level evidence-based conclusions.

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Safety and effectiveness of negative pressure therapy on free flaps following lower limb reconstruction: A systematic review

Journal of Plastic Reconstructive & Aesthetic Surgery ◽

10.1016/j.bjps.2020.08.080 ◽

2020 ◽

Author(s):

Juan Enrique Berner ◽

Patrick Will ◽

Luke Geoghegan ◽

Luigi Troisi ◽

Jagdeep Nanchahal ◽

...

Keyword(s):

Systematic Review ◽

Negative Pressure ◽

Lower Limb ◽

Free Flaps ◽

Negative Pressure Therapy ◽

Pressure Therapy ◽

Limb Reconstruction ◽

Lower Limb Reconstruction

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A systematic review of the applications of free tissue transfer for paediatric lower limb salvage following trauma

Journal of Plastic Surgery and Hand Surgery ◽

10.3109/2000656x.2015.1047781 ◽

2015 ◽

Vol 49 (5) ◽

pp. 251-259 ◽

Cited By ~ 1

Author(s):

Shehab Jabir ◽

Fayad Sheikh ◽

Edmund Fitzgerald O’Connor ◽

Matthew Griffiths ◽

Niri Niranjan

Keyword(s):

Systematic Review ◽

Limb Salvage ◽

Lower Limb ◽

Free Tissue Transfer ◽

Tissue Transfer

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The Role of Negative-Pressure Wound Therapy in Lower-Limb Reconstruction

Indian Journal of Plastic Surgery ◽

10.1055/s-0039-1687922 ◽

2019 ◽

Vol 52 (01) ◽

pp. 073-080 ◽

Cited By ~ 4

Author(s):

Renita Sirisena ◽

Gregory Lucien Bellot ◽

Mark Edward Puhaindran

Keyword(s):

Negative Pressure ◽

Lower Limb ◽

Negative Pressure Wound Therapy ◽

Bacterial Load ◽

Free Tissue Transfer ◽

Wound Therapy ◽

Limb Reconstruction ◽

Lower Limb Reconstruction ◽

Tibia Fractures

AbstractNegative-pressure wound therapy (NPWT) has gained increasing popularity among clinicians since its introduction in 1997 as a potential aid to wound healing. Multiple benefits of NPWT have since been proven in studies, including increase in granulation tissue formation, decrease in bacterial load, and the improved survival of flaps. With our increasing use and greater understanding of the tissue and cellular changes that occur in a wound treated with NPWT, our lower-limb reconstructive practice has also evolved. Although controversial, the definite timing for lower-limb reconstruction has stretched from 72 hours to longer than 2 weeks as NPWT contains the wound within a sterile, closed system. It has also shown to decrease the rate of infection in open tibia fractures. Previously, a large number of critical defects of the lower limb would require free tissue transfer for definitive reconstruction. NPWT has reduced this rate by more than 50% and has allowed for less complicated resurfacing procedures to be performed instead.

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