[Vascular diagnostics before microvascular tissue transfer on the lower extremities : An algorithm]

[Revascularization Prior to Defect Reconstruction of the Lower Limb - Essential Cooperation between Plastic and Vascular Surgery]

Treatment of complex ischemic lower leg defects with exposure of deep anatomic structures represents a considerable challenge to involved specialties. In selected patients, limb salvage can be achieved as an alternative to major amputation by means of a combined approach including arterial reconstruction and subsequent free flap transfer. Arterial reconstruction can be performed either by endovascular or open surgical treatment (bypass reconstruction or implantation of an arteriovenous loop) preliminary to defect reconstruction using microsurgical free flap transplantation. Whereas the aim of the arterial reconstruction comprises the establishment of sufficient perfusion and creation of adequate target vessels for the free flap transfer, the selection of the appropriate flap entity depends on the extent of the wound as wells as on the presence of osteomyelitis. Arterial reconstruction and defect reconstruction can be performed as one-stage or two-stage procedure and has become an established and feasible treatment approach in centers. Evaluation of microperfusion by means of indocyanine green can further increase safety and feasibility of this method. Against this background, combined arterial reconstruction and subsequent free flap transfer provides excellent results in terms of amputation free survival and postoperative mobility. Essential is however an individualized decision making in consideration of patient selection and possible contraindications. This approach may be evaluated in mobile patients with complex wounds prior to major amputation.

[Autologous tissue reconstruction of the lower extremity-indications and technique]

Autologous tissue reconstruction for defect coverage of lower extremity wounds describes a broad interdisciplinary spectrum of conservative, surgical and interventional treatment options. The goals of reconstruction are a resilient and function-preserving but also esthetically acceptable wound closure, which should enable rehabilitation and the return to participation in social and working life for those affected. Depending on the wound conditions as well as on potentially occurring concomitant injuries and comorbidities, the timing and method of defect coverage is selected in an individualized approach for each patient. It is essential that the plastic surgeon is involved as early as possible in the preparation of a treatment plan and can then select the most appropriate and least invasive reconstructive procedure from the armamentarium, depending on the localization and etiology of the soft tissue defect. These vary from secondary wound closure to skin grafts up to local and free flaps.