Microsurgical free flap transfer to amputation sites: indications and results

The versatility of the scapular free flap: A workhorse flap? A systematic review and meta-analysis

BACKGROUND

The scapular free flap (SFF) is essential in complex reconstructive surgery and often indicated in complex defects with compromised or poor local tissue integrity. This review aims to assess the versatility and reliability of the SFF during reconstruction.

METHODS

A comprehensive literature review of multiple databases was conducted following the PRISMA guidelines. An analysis of pooled data was performed to evaluate flap failure rate for any anatomical unit using SFF as the primary endpoints. Secondary endpoints included other complication rates after reconstruction such as partial flap loss, revision surgery, fistula, hematoma, and infection.

RESULTS

A total of 110 articles were included, with 1447 pooled flaps. The main recipient site was the head and neck region (89.0%). Major indications for reconstruction were malignancy (55.3%), burns (19.2%), and trauma (9.3%). The most common types of flaps were osteocutaneous (23.3%), cutaneous (22.6%), and chimeric (18.0%). The pooled flap failure rate was 2% (95%CI: 1%-4%). No significant heterogeneity was present across studies (Q statistic 20.2, p = .69; I2 .00%, p = .685). Nonscapular supplementary flaps and grafts were required in 61 cases. The average length and surface area of bone flaps were 7.2 cm and 24.8cm2, respectively. The average skin paddle area was 134.2cm2.

CONCLUSION

The SFF is a useful adjunct in the reconstructive surgeon's armamentarium as evidence by its intrinsic versatility and diverse clinical indications. Our data suggest a low failure rate in multicomponent defect reconstruction, especially in head and neck surgery. SFFs enable incorporation of multiple tissue types and customizable dimensions-both for vascularized bone and cutaneous skin-augmenting its value in the microsurgeon's repertoire as a chimeric flap. Further research is necessary to overcome the conventional barriers to SFF utilization and to better comprehend the specific scenarios in which the SFF can serve as the preferred alternative workhorse flap.

Emergency Foot Fillet Free Flap Based on Posterior Tibial Vessels for Reconstruction of Contralateral Heel and Sole: A Unique Spare Part Surgery

Introduction

Reconstruction of the sole is an extremely challenging problem for a reconstructive microsurgeon. The specialized nature of its skin and subcutaneous tissue makes reconstruction arduous. When posed with complex bilateral lower extremity trauma where one limb was nonsalvageable, we harvested the uninjured foot fillet flap for free flap cover to reconstruct the contralateral sole. We report two such cases with follow-up assessment.

Patients and Methods

Two cases of sole reconstruction with emergency foot fillet free flap scavenged from the amputated contralateral limb were retrospectively analyzed. In both the patients, foot fillet free flap based on the posterior tibial neurovascular bundle was used. The follow-up assessment data collected included flap status, presence of any complications and prosthesis use, and functional status of the limbs at final follow-up.

Results

Both the free flaps survived. Postoperative period was uneventful. No complications such as wound infection, delayed healing, flap necrosis, or scar breakdown were noted. The plantar flaps had recovery of protective sensation. Both the patients are ambulant; the first man with a fitted prosthesis and the second woman with the aid of a walker.

Conclusion

The opportunity to utilize spare tissue from the amputated limb should be seized. Loss of the plantar aspect of foot poses a real challenge. The plantar foot fillet free flap is a durable flap with preservation of plantar sensations. It is probably the best choice as it replaces "like with like." Prerequisites for utilizing the "spare part surgery" concept are meticulous initial debridement as well as emergency free tissue transfer, which require senior input and excellent infrastructure.

From replantation to transplantation: The evolution of orthoplastic extremity reconstruction

For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.

Microvascular free flaps from the lower abdomen for preservation of amputation length in the lower extremity

BACKGROUND

The length of the amputation stump is crucial for optimal prosthetic fitting and rehabilitation. Especially in traumatic amputation, direct closure of the stump may be challenging, and bone shortening is frequently needed. To avoid excessive bone shortening, coverage of exposed bone with free flaps is a versatile option.

OBJECTIVE

Here we present our experience with the utilization of free flaps from the lower abdomen for the coverage of amputations stumps of the lower extremity.

METHODS

Between March 2008 and October 2010, five patients (three female, two male) with complex wounds on amputation stumps of the lower extremity were treated with a mean age of 50 years (range: 15-72 years). Six abdominal free flaps were performed in five patients (one bilateral case), including four deep inferior epigastric artery (DIEP-) and two muscle-sparing transverse rectus abdominis muscle (ms-TRAM-) flaps. Patient's and operative data were collected retrospectively.

RESULTS

One complete flap failure occurred (overall success rate: 83.3%). Three of five patients gained full ambulatory status.

CONCLUSIONS

Due to the low donor site morbidity a long vascular pedicle and the large amount of available tissue, abdominal based free flaps represent our first choice for microsurgical reconstruction of lower extremity stumps.

Reinventing Extremity Amputation in the Era of Functional Limb Restoration

BACKGROUND

Recent progress in biomechatronics and vascularized composite allotransplantation have occurred in the absence of congruent advancements in the surgical approaches generally utilized for limb amputation. Consideration of these advances, as well as of both novel and time-honored reconstructive surgical techniques, argues for a fundamental reframing of the way in which amputation procedures should be performed.

METHODS

We review sentinel developments in external prosthetic limb technology and limb transplantation, in addition to standard and emerging reconstructive surgical techniques relevant to limb modification, and then propose a new paradigm for limb amputation.

RESULTS

An approach to limb amputation based on the availability of native tissues is proposed, with the intent of maximizing limb function, limiting neuropathic pain, restoring limb perception/proprioception and mitigating limb atrophy.

CONCLUSIONS

We propose a reinvention of the manner in which limb amputations are performed, framed in the context of time-tested reconstructive techniques, as well as novel, state-of-the-art surgical procedures. Implementation of the proposed techniques in the acute setting has the potential to elevate advanced limb replacement strategies to a clinical solution that perhaps exceeds what is possible through traditional surgical approaches to limb salvage. We therefore argue that amputation, performed with the intent of optimizing the residuum for interaction with either a bionic or a transplanted limb, should be viewed not as a surgical failure, but as an alternative form of limb reconstruction.

Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities

Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.

Comparison of Fasciocutaneous and Muscle-based Free Flaps for Soft Tissue Reconstruction of the Upper Extremity

Soft tissue free flap reconstruction of upper extremities has proven to be reliable and essential for limb salvage and function. Nevertheless, comparative data regarding flap outcome are still lacking. The present study aimed to compare procedural features and individual complication rates of different free flaps used for upper extremity reconstruction.

Methods

The authors evaluated retrospectively the results of 164 free flaps in 149 patients with upper extremity defects. Chart reviews were performed from April 2000 to June 2014, analyzing flap choices, complication, and success rate assessment for patients >18 years old, with a soft tissue defect of the upper extremity. Chosen flap types were classified as fasciocutaneous (including adipocutaneous) and muscle-based, respectively. We comparatively analyzed total flap loss, flap survival after microsurgical revisions, and susceptibility rates for thromboses rates and partial flap necrosis.

Results

Defect size was larger when muscle-based flaps were used (231 ± 38.6 versus 164 ± 13.7 cm², P < 0.05). Outcome analysis revealed a tendency towards higher arterial thrombosis rates for muscle flaps (10.2% versus 4.3%) and venous thrombosis rates for fasciocutaneous flaps (2% versus 7%). Total flap loss (6.1% versus 7.8%) and flap survival after vascular revisions (75% versus 70.6%) showed comparable rates. Partial flap necrosis was generally higher in muscle-based flaps (22.4% versus 8.6%, P = 0.02) with impact on patients' hospital stay (37.2 ± 4.69 and 27.11 ± 1.62 days, n = 115, P = 0.01), while no differences in partial necrosis rates were noted in flaps larger than 300 cm² (25% versus 10%, P = 0.55). There was a trend over time towards using fasciocutaneous-based flaps more frequently with a final overall percentage of 83.7% between 2012 and 2014.

Conclusions

Microsurgical tissue transfer to the upper extremity is safe and reliable, but flap-type specific procedural and measures should be taken into consideration. Total flap loss as well as flap survival after microsurgical revisions are not altered between these flaps. They differ, however, in their susceptibilities for thromboses rates, partial flap necrosis and thus require individual risk stratification and flap placement.

The Microsurgical Calcaneus Osteocutaneous Fillet Flap After Traumatic Amputation in Lower Extremities: Flap Design and Harvest Technique

BACKGROUND

Attempts to salvage upper and lower extremities have performed more frequently in recent decades, although there are clear cases that cannot be salvaged. The purpose of this retrospective study was to present our experience in using free calcaneus osteocutaneous fillet flap for preserving below-knee amputation stump after traumatic amputations or functional preserving after nonsalvageable lower extremities.

METHODS

Between January 2012 and May 2017, 11 free calcaneus osteocutaneous fillet flap were used to preserving or lengthening below-knee amputation stump secondary to amputation on 8 males and 3 females. Patients' information and postoperative data were collected, including age of patient, sex, amputation site, flap survival, sensation recovery, and number of complications.

RESULT

All amputations were trauma related and secondary to motor vehicle accidents (n = 8) and industrial accidents (n = 3). The age of the patients ranged from 16 to 59 years, with a mean of 34.4 years. Free calcaneus osteocutaneous fillet flap were designed and harvested from all patients. All flaps survived and 2 complications developed in 2 patients. Nine of 11 patients obtained protective sensory recovery during the period of follow-up.

CONCLUSIONS

The free calcaneus osteocutaneous fillet flap harvested from the amputated limb provides reliable and robust tissue for reconstruction of large defects of the residual limb without additional donor-site morbidity.

Preservation of lower extremity spare parts using the University of Wisconsin solution

The management of a mangled limb is a challenging endeavor. With the advancement in microsurgery, spare parts surgery (fillet flaps) has gained recent interest. In the context of lower extremity amputation secondary to trauma, viable spare parts can provide stump soft tissue coverage, potentially preserving critical length and obviating above-knee amputations. Commonly, spare parts surgery is performed in the acute setting but tissue preservation is sometimes necessary. The authors report their experience preserving a fillet flap of a mangled lower extremity for 48 h using the University of Wisconsin solution. A sole fillet flap and a split-thickness skin graft were harvested and preserved from the amputated lower extremity (based on the posterior tibial artery and vein). Stump coverage was achieved by anastomosing the fillet flap to the proximal posterior tibial artery and vein. This solution has not been previously described for preservation of fillet flaps.

Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities

Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.

Factors affecting outcome after traumatic limb amputation

BACKGROUND

Traumatic leg amputation commonly affects young, active people and leads to poor long-term outcomes. The aim of this review was to describe common causes of disability and highlight therapeutic interventions that may optimize outcome after traumatic leg amputation.

METHODS

A comprehensive search of MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases was performed, using the terms 'leg injury', 'amputation' and 'outcome'. Articles reporting outcomes following traumatic leg amputation were included.

RESULTS

Studies demonstrated that pain, psychological illness, decreased physical and vocational function, and increased cardiovascular morbidity and mortality were common causes of disability after traumatic leg amputation. The evidence highlights that appropriate preoperative management and operative techniques, in conjunction with suitable rehabilitation and postoperative follow-up, can lead to improved treatment outcome and patient satisfaction.

CONCLUSION

Patients who undergo leg amputation after trauma are at risk of poor long-term physical and mental health. Clinicians involved in their care have many opportunities to improve their outcome using a variety of therapeutic variables. Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Proximal sural traction neurectomy during transtibial amputations

Symptomatic neuroma formation after trauma-related transtibial amputations remains a clinical problem. The sural nerve is frequently overlooked in its vulnerable subcutaneous location in the posterior myofasciocutaneous flap and commonly leads to chronic pain and decreased prosthesis use. The standard sural traction neurectomy may actually predispose the sural neuroma to form in a region that becomes symptomatic with prosthesis wear. The proposed modified proximal sural traction neurectomy using a standard or extended posterior flap begins with identification of the sural nerve in the subcutaneous tissue of the distal flap in identical fashion to a standard sural neurectomy. In the proximal posterior flap, a limited anterior approach is then performed and gentle traction on the distal end of the sural nerve aids in the identification of the most proximally accessible portion of the medial sural cutaneous nerve. After locating the medial sural cutaneous nerve proximally, a neurectomy at this location is performed, allowing the retraction of the nerve into a healthy tissue bed substantially more proximal than with a standard sural neurectomy. This technique ensures that the resulting neuroma does not form directly at the distal end of the residual limb where it is, in our experience, more likely to become symptomatic.

Secondary reconstruction of below knee amputation stump with free anterolateral thigh flap

Below knee stump preservation reduces ambulatory energy expenditure and improves the quality of life. Reconstruction of soft tissue loss around the stump is a challenging task. Below knee stump reconstruction demands stable skin with sufficient soft tissue to allow weigh bearing. Microsurgical tissue transfer is increasingly being used as a salvage option. Anterolateral thigh flap with additional vastus lateralis muscle provides extra cushioning effect. We report two cases of amputation below knee successfully salvaged. The anterolteral flap with abundant tissue and stable skin offers a reliable option for cover. Two patients with below knee amputation were reconstructed secondarily. After 6 to 20 months of follow -up, stumps showed no signs of pressure effects. Patients are able to bear 50-70 hours of weight per week.

The respective roles of plastic and orthopedic surgery in limb salvage

The evolution of techniques in plastic surgery and orthopedic surgery over the past few decades has enabled a great level of success in limb salvage. Limb salvage can now be achieved when faced with trauma, tumor, sepsis, or vascular disease. In fact, "What can be salvaged?" is now a less common debate among clinicians than "What should be salvaged?" Often discussions among surgeons from various subspecialties, including orthopedics, plastics, trauma, and vascular surgery, are characterized by how each of them can perform their respective part of the salvage operation, be it bony fixation, revascularization, or soft-tissue coverage, but none of them is certain whether it should be attempted. What is needed in these clinical situations is an interdisciplinary team approach led by individual or groups of clinicians who are familiar not only with their own subspecialized skills but also with those of their colleagues and the outcomes associated with integrated efforts at limb salvage. The concept of orthoplastic surgery is based on such an idea, where the combined skills and techniques of the orthopedic surgeon and reconstructive microsurgeon are used in concert to direct efforts toward limb salvage or decide against it when it is not indicated. This article presents a review of the roles of the two subspecialties and how an orthoplastic team can function with the current techniques to improve outcomes in limb salvage surgery.

Traumatic and trauma-related amputations: part I: general principles and lower-extremity amputations

Deliberate attention to the management of soft tissue is imperative when performing an amputation. Identification and proper management of the nerves accompanied by the performance of a stable myodesis and ensuring robust soft-tissue coverage are measures that will improve patient outcomes. Limb length should be preserved when practicable; however, length preservation at the expense of creating a nonhealing or painful residual limb with poor soft-tissue coverage is contraindicated. While a large proportion of individuals with a trauma-related amputation remain severely disabled, a chronically painful residual limb is not inevitable and late revision amputations to improve soft-tissue coverage, stabilize the soft tissues (revision myodesis), or remove symptomatic neuromas can dramatically improve patient outcomes. Psychosocial issues may dramatically affect the outcomes after trauma-related amputations. A multidisciplinary team should be consulted or created to address the multiple complex physical, mental, and psychosocial issues facing patients with a recent amputation.

Complex reconstruction of a massive shoulder and chest wall defect: de-bone appétit flap

We report the use of a fillet of upper arm pedicled flap, which has not been previously reported in the literature. The fillet of upper arm flap follows the principle of "spare parts" surgery, and can provide vascularized soft tissue coverage for defects of the shoulder and the chest wall when the upper extremity cannot otherwise be salvaged, such as in cases of radical tumor excision. The fillet of upper arm pedicled flap was used to successfully cover a large shoulder and chest wall defect measuring 25 cm x 15 cm. This "spare parts" reconstructive technique has several advantages over the previously reported forearm free flap, including minimal need for microsurgery and the ability for expansion to cover larger defects. This case demonstrates effective use of fillet of upper arm flaps in reconstruction of large defects of the shoulder and chest wall.

Reconstruction of massive oncologic defects using free fillet flaps

BACKGROUND

Forequarter and hind-limb amputations are used with curative and palliative intent in the setting of proximal limb, thorax, or truncal malignancies. For these large defects that require a free flap, the distal portions of these limbs can be harvested as fillet flaps and represent the "spare parts" concept of surgical reconstruction.

METHODS

The authors performed a retrospective review of 27 patients (mean age, 51.4 years) who had undergone immediate reconstruction with free fillet extremity flaps between 1991 and 2008. Seventeen patients received preoperative radiotherapy, and 21 received preoperative chemotherapy. Resections included seven hemipelvectomies, 16 forequarter amputations, and four hindquarter amputations.

RESULTS

The mean defect size was 1126 cm (range, 480 to 3500 cm). All 27 flaps survived and all wounds healed. Four patients (15 percent) had complications; three patients developed partial flap necrosis and required operative débridement, and there were two episodes of flap vascular compromise. Mean follow-up time was 14 months. One patient was lost to follow-up. Eight patients (30 percent) were still alive at the end of the study. The remaining 18 patients died within 22 months of resection, for a mean survival of 7 months. There was no cancer recurrence within the flap itself. Phantom pain occurred in 11 patients. At the time of discharge, pain, tissue necrosis, and infection were improved in all patients.

CONCLUSION

The use of the fillet flap is oncologically sound, has no associated donor sites, has an acceptable incidence of major complications, and allows for a healed wound with an improvement in the quality of life.

Traumatic amputation — a contemporary approach

The management of patients with loss or near loss of a limb secondary to high-energy trauma is particularly challenging. Management consists of an acute phase of resuscitation and initial surgery, followed by a longer chronic phase, consisting of rehabilitation, fitting of a prosthesis and stump care. Acute assessment by the full trauma team along standard 〈C〉ABCDE guidelines should not conflict with early stemming of on-going stump or limb haemorrhage as required. Patients with traumatic limb loss are likely to be shocked and have traumatic coagulopathy; initial and on-going resuscitation should satisfy the need to replace blood with packed cells and plasma in a 1 : 1 ratio consistent with the concept of `Damage Control Resuscitation'. The surgical goal is to tailor surgery to the patients' physiological state, removing dead and unviable tissue, restoring perfusion to live tissue, stabilising fractured bone and addressing the loss of soft tissues. The imperative to preserve length should not outweigh the need to leave the patient with a stump that will heal in a timely fashion. Lifelong prosthetic preventive maintenance is paramount as residual limbs change in volume with muscle atrophy and changes inpatient weight. Replacement may also be indicated as improved designs appear from time to time. Early rehabilitation and prosthetic fitting also improves routine prosthetic use, which has been found to positively affect return to work.

Reconstruction modality based on the spare part concept for massive soft tissue defects following oncological hemipelvectomy

BACKGROUND

Hemipelvectomy for massive malignancy can result in large soft tissue defects that cannot be reconstructed using conventional posterior flaps. For such cases, reconstruction methods, including a latissimus dorsi flap or a rectus abdominis myocutaneous flap, may be applied, resulting in donor site morbidity. Recent innovations in plastic surgery have resulted in the development of novel reconstruction modalities based on "the spare part concept," applying tissues from amputated limbs.

METHODS

Five subjects with pelvic malignant tumors underwent hemipelvectomy with reconstruction using the spare part concept. Femoral artery-based myocutaneous flap and free fillet lower leg flap were used for three and two cases, respectively. The clinical results, including postoperative complications and oncological outcomes, were assessed.

RESULTS

The mean follow-up period was 43.2 months (range 12-94 months). No local recurrence was encountered in any cases throughout follow-up. As of the final follow-up, three patients remained alive and two patients were dead due to distant metastasis. Minor postoperative infection was observed in two cases.

CONCLUSIONS

The femoral artery-based myocutaneous flap and the free fillet lower leg flap are both useful, safe options for reconstruction of the large defect following extensive hemipelvectomy for malignant bone and soft tissue tumors. The present data support the continued application of these flap reconstruction techniques based on the spare part concept.

Composite tissue transfer in upper extremity trauma

Unlike congenital malformations or defects resulting from tumour ablation, trauma of the upper extremity is more complex to manage. Also because of the structural complexity of the upper extremity, tissue defects often result in exposure of vital structures such as bone, nerve, blood vessels and tendons. Thus, a successful reconstruction after upper extremity trauma must be approached with the goals of not only providing stable coverage but most importantly, restoring function. We present the state-of-the-art material on composite tissue transfer in upper extremity trauma. This chapter describes the modern philosophy of emergency wound management, the optimal timing of reconstruction, and the basic principles in selection of coverage tissue, as well as outlining the advantages, disadvantages, and indications of several most commonly used flaps. In our opinion, radical debridement followed by primary reconstruction is always the first choice when treating traumatic injuries. Microsurgical transplantation of composite tissue to the upper extremity results in the best wound coverage and early functional rehabilitation. Simultaneously, multicomponent reconstruction can also be achieved with minimal donor site morbidity and aesthetically acceptable donor sites.

Amputation stump salvage using a free forearm flap from the amputated part

Upper extremity amputations are not as common as lower extremity amputations, but they present unique challenges to the surgeon, prosthetist and amputee. The tissues of amputated or non-salvageable limbs may be used to reconstruct complex defects resulting from tumour removal or trauma, i.e. the 'spare parts' concept. The use of a free fillet flap to treat massive trauma of the upper extremity is reported here for two cases. These patients were treated with a pedicled fillet of whole forearm flaps to achieve primary stump closure and to preserve upper arm length.

Free Vascularized Tissue Transfer to Preserve Upper Extremity Amputation Levels

BACKGROUND

Free vascularized tissue transfer to preserve upper extremity amputation level is an uncommon procedure. The authors investigate the role of free tissue transfer in preserving both morphology and function of the amputated upper extremity, with the goal of facilitating prosthetic rehabilitation.

METHODS

Thirteen patients who underwent microsurgical free tissue transfer to preserve upper extremity amputation level were reviewed retrospectively. These cases were selected from four centers: Duke University Medical Center (Durham, N.C.) University Hospital of Modena (Modena, Italy), Careggi University Hospital (Florence, Italy), and the University of Heidelberg (Heidelberg, Germany). Parameters that were evaluated included age, sex, cause of the defect, reconstructive procedure, structures to be salvaged, and functional outcome, among others.

RESULTS

The cause of amputation was trauma in 92 percent of patients. Mean age was 32 years. In 31 percent of the cases, an emergency free fillet flap was used, and in the remaining 69 percent, a traditional free flap was performed. Structures/function to be preserved included pinch function to the hand, function of the elbow and shoulder joints, and skeletal length greater than 7 cm. Complications occurred in 38 percent of the cases, but the final goal of the procedure was achieved in all cases. A treatment algorithm for the management of the amputated upper extremity is presented.

CONCLUSION

Use of free vascularized tissue transfer for preservation of upper extremity amputation level in well-selected cases facilitates prosthetic rehabilitation and improves residual limb function.

The Fate of Lower Extremities With Failed Free Flaps

BACKGROUND

Lower-extremity reconstruction with microvascular free flap coverage is often the only option for limb salvage. Flap failure rates, however, continue to have higher complication rates than those to other anatomic sites; a significant number of flaps that fail result in amputation. This study retrospectively analyzed patients treated at a single institution who underwent attempted lower-extremity limb salvage with microsurgical techniques over a 25-year period. Of particular interest are the outcome data for patients who had initial free flap failure.

PATIENTS AND METHODS

A prospectively maintained database was used to identify patients who satisfy criteria. Every patient who was treated with a microvascular free flap to their lower extremities was identified and included in this analysis. All records were reviewed from 1980 through 2004. Patients who had free flaps to the lower extremity fail after the initial operation were identified and selected for further analysis.

RESULTS

Five hundred eighty-eight patients who underwent microsurgical reconstruction of lower extremity wounds had a failure rate of 8.5%. Trauma patients (83%) had a failure rate of 9%. On subset analysis, the failure rate for trauma patients decreased from 11% (1980-1992) to 3.7% (1993-2004). Of patients who had a failed free flap, 18% went on to limb amputation; the remainder was salvaged with secondary free flaps, local flaps, or skin grafting.

CONCLUSION

This single institutional experience spanning 25 years represents the longest continual series of lower-extremity free flaps reported in the literature. The improved success rate seen in the second half of the study period is attributed to a more critical selection of free-flap candidates, improved understanding of the physiology surrounding acute trauma and a more sophisticated multidisciplinary team organization.

Extremity Reconstruction Using Nonreplantable Tissue (“Spare Parts”)

After a severe digital or extremity injury, the replantation surgeon should always seek to make the best use out of what tissue is available for reconstruction. Exercising sound surgical judgment and being creative allow the surgeon to restore function to critical areas of the hand or extremity by the judicious use of available tissues that would otherwise be discarded. The use of "spare parts" should, therefore, always be considered to facilitate digital or extremity reconstruction when routine replantation is not possible or is likely to produce a poor functional result. The surgeon should always try to use available nonreplantable tissue to preserve length, obtain soft tissue coverage, or most importantly improve the function of remaining less injured digits. This article presents several case studies that illustrate the principals of spare parts reconstruction performed at the time of the initial debridement using nonreplantable tissue to provide coverage or improve function.

Reliable option for reconstruction of amputation stumps: The free anterolateral thigh flap

The increased use of microsurgery has enabled reconstructive surgeons to deal with tissue defects of various sizes and compositions. The limited amount of qualified tissue for covering is the primary problem in stump reconstruction. Free flaps offer the ideal solution by providing the optimal cover, and by preserving the length of the amputation site. Anterolateral thigh flaps were preferred for reconstruction of lower extremity amputation sites of nine patients admitted both in the subacute and chronic periods. All underwent previous stump reconstruction with local flaps in other clinics. Anterolateral thigh flaps avoided further shortening of the extremities, and provided stable tissue for prosthesis use. The flap offers reliable soft-tissue reconstruction of amputation stumps.

The versatile DIEP flap: its use in lower extremity reconstruction

The deep inferior epigastric perforator (DIEP) flap gained widespread popularity as a free flap in breast reconstruction. It is also a versatile and reliable supply of a large amount of skin and soft-tissue, which can be used in other types of reconstruction. We present 25 consecutive cases (28 DIEP flaps) performed in our service during the past 5 years for different indications in lower extremity aesthetic and functional reconstruction, both as pedicled or free flaps. The amount of tissue provided, its reliable vascular supply and long and adequately sized pedicles, together with its limited donor-site morbidity make it a useful alternative free flap.

Reconstruction of a transmetatarsal amputation stump using a salvaged peroneal artery fasciocutaneous flap from the opposite leg: A case report

During lower extremity amputation, the objective is to provide a functional residual limb that permits maximum patient mobility and independence. Preservation of length of the fore part of the foot using salvageable tissue from the amputated part in young patients prevents equines deformity and revision of amputation to a higher level. This can be achieved using tissue available from the amputated part. The spare part concept in reconstructive surgery should be integrated into the trauma algorithm to avoid additional donor site morbidity. Reported here is a young adult patient with crush injuries to both feet, which resulted in amputations. A fasciocutaneous flap raised from one extremity was used to facilitate transmetatarsal amputation stump length preservation of the other extremity.