Lower Extremity Reconstruction Using Vastus Lateralis Myocutaneous Flap versus Anterolateral Thigh Fasciocutaneous Flap. Arch Plast Surg. 2012;39:367-375. [PMID: 22872841 PMCID: PMC3408283 DOI: 10.5999/aps.2012.39.4.367]

How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis

Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.

Muscle/musculocutaneous versus fasciocutaneous free flap reconstruction in the lower extremity: A systematic review and meta-analysis

BACKGROUND

Free flaps for soft tissue coverage of the lower extremity can be broadly divided into muscle/musculocutaneous and fasciocutaneous flaps. The purpose of this systematic review and meta-analysis was to assess their different post-operative outcomes.

METHODS

A systematic search was performed in PubMed, Scopus, and the Web of Science from their inception to February 2022. Non-randomized comparative studies, which describe any post-operative outcome of muscle/musculocutaneous and fasciocutaneous free flaps reconstruction in the lower extremity were included. Articles with duplicate titles, editorials, review articles, case series, case reports, and publications lacking an abstract, those reporting pediatric patients, those describing only muscle/musculocutaneous or fasciocutaneous free flaps, those with incomplete or incomparable post-operative outcomes, and studies involving <10 muscle/musculocutaneous or fasciocutaneous free flaps were excluded. A comparative meta-analysis was conducted on muscle/musculocutaneous and fasciocutaneous free flaps outcomes, comprising vascular thrombosis, partial or complete flap necrosis, infection, donor-site complications, non-union, and primary or recurrent osteomyelitis. The fixed-effects meta-analysis model was used when low heterogeneity (I²  < 50%) was identified.

RESULTS

Twenty-two articles with a total of 2711 flaps (1584 muscle/musculocutaneous flaps and 1127 fasciocutaneous flaps) were included in the qualitative and quantitative assessment. The rates of any flap necrosis (12.0% vs. 7.4%; p = 0.007) and donor-site complications (16.7% vs. 6.7%; p < 0.0001) were significantly higher for muscle/musculocutaneous flaps than for fasciocutaneous flaps. There were no significant differences in the rates of vascular thrombosis (10.5% vs. 10.7%; p = 0.98), complete flap necrosis (6.2% vs. 4.7%; p = 0.30), infection (19.4% vs. 14.7%; p = 0.18), non-union (18.9% vs. 14.8%; p = 0.33), and primary or recurrent osteomyelitis (14.7% vs. 12.4%; p = 0.69).

CONCLUSION

This meta-analysis revealed no significant difference in long-term post-operative outcomes, but suggested that fasciocutaneous flaps should be preferred to avoid flap necrosis and donor-site complications.

Pedicled vastus lateralis myocutaneous flap for sacropelvic defects after wide oncologic resection: Wound complications and outcomes

BACKGROUND AND OBJECTIVES

Adequate coverage of the soft tissue defects from wide resection of sacropelvic malignancies remains challenging. The vastus lateralis flap has been described for coverage in the setting of trauma and infection. This flap has not been described for coverage of sacropelvic tumor defects.

METHODS

This is a retrospective cohort study of adult patients who underwent wide resection of a primary sacropelvic malignancy with reconstruction employing a pedicled vastus lateralis flap at two tertiary care centers. Patient demographics, tumor staging, and rate of complications were assessed.

RESULTS

Twenty-eight patients were included, with a median age of 51 years. The most common primary tumor was chondrosarcoma followed by chondroblastic osteosarcoma. The median follow-up was 1.1 years. There were 10 cases of wound infection requiring re-operation and three cases of flap failure.

CONCLUSIONS

We describe a pedicled vastus lateralis flap for coverage of defects after wide resection of sacropelvic malignancies. A large proportion of our cohort had independent risk factors for wound complications. Even with a cohort with high baseline risk for wound complications, we show that the use of a pedicled vastus lateralis flap is a safe reconstructive option with a wound complication rate in line with the literature.

"Outcomes of Local versus Free Flaps for Lower Extremity Trauma"

BACKGROUND

Lower extremity reconstruction often requires soft tissue transfer for limb salvage. Flaps are allocated based on injury size, location, and shape coupled with surgeon expertise. Ideally, vascularized tissue should have similar outcomes across local and free tissue transfers. By evaluating outcomes from a Level 1 trauma center, we aim to provide recommendations regarding surgical management of leg reconstruction with respect to local versus free flap implementation.

METHODS

This retrospective review evaluated patient medical history, demographics, flap characteristics, and outcomes from LAC + USC between 2007-2021 using an internal database. Outcomes included failure rates, complications, and ambulation.

RESULTS

357 lower extremity flaps were placed on 322 patients; 187 (52.4%) were local and 170 (47.6.%) were free flaps. Twenty-one (11.2%) local flaps suffered significantly more postoperative hardware infections and/or osteomyelitis compared to nine (5.3%) free flaps. Eleven (5.9%) local flaps developed partial necrosis, four requiring revision; 12 (6.4%) total local flaps required revision. Comparatively, sixteen (9.4%) free flaps developed partial necrosis, seven requiring revision; 18 (10.6%) total free flaps required revision. Flap survival was 96.3% for local versus 93.5% for free flaps. Percentage of fully ambulatory patients and time to final ambulation was not significant across cohorts.

DISCUSSION

Local flaps may portent higher risk for infection; though the cause is not clear, the results may be confounded by comorbidities. Nevertheless, there were no significant differences in flap survival or number of fully ambulatory patients across cohorts. Future studies should evaluate aesthetic results and patient satisfaction across flap types.

Assessment of post-surgical donor-site morbidity in vastus lateralis free flap for head and neck reconstructive surgery: An observational study

BACKGROUND

Vastus lateralis (VL) can be used to reconstruct defects of the head and neck. Whilst the advantages are documented, donor-site morbidity is not well described. This study aimed to assess donor-site morbidity after VL flap harvest. Results will determine future directions for preventative and post-operative care to improve patient health outcomes.

METHODS

Ten participants (mean age 55 years) were assessed for the presence of donor-site morbidity after VL harvest. Musculoskeletal (pain, muscle strength, muscle length and tactile sensation), quality of life (SF-12), lower extremity function, gait (function and speed) and sit to stand were assessed using validated and standardized procedures. The outcomes were compared to age-matched healthy reference values or to the non-operative side. Analyses were conducted using descriptive statistics and non-parametric tests.

RESULTS

There was no difference in muscle strength (knee extension), muscle length, ability to sit-to-stand, or gait function (all P > 0.05). Knee flexor muscle strength was significantly less on the operated leg compared to the non-operated leg (P = 0.02) and walking speed was slower than age-matched healthy values (P < 0.001). Thigh tactile sensation was impaired in 89% of participants. Quality of life was significantly less for the physical health component of the SF-12 (P < 0.001). The mental health component of the SF-12 was similar to healthy controls (P = 0.256).

CONCLUSION

There was no effect on donor site morbidity with regards to knee extensor strength, pain, walking function, ability to sit-to-stand and muscle length. VL harvest affected donor-site knee flexion strength, walking speed, tactile sensation and physical health-related quality of life.

Reconstruction of burn scar contracture deformity of the extremities using thin thoracodorsal artery perforator free flaps

BACKGROUND

Severe burn scar contracture of the extremities, especially the joint areas, causes aesthetic problems and functional limitation. Release of burn scar contractures requires complete removal of the scars and resurfacing of the resulting defects. Here, we describe thoracodorsal artery perforator (TDAP) free flaps for reconstructing burn scar contractures.

METHODS

Between August 2013 and July 2018, 25 patients with severe burn scar contractures of the extremities underwent reconstruction using TDAP free flaps. Twelve were men and the mean age of the patients was 38.1 years (range, 12-66 years). Five patients had upper extremity contractures and 20 had lower extremity contractures.

RESULTS

Twenty-one patients underwent reconstruction with a TDAP flap alone, while three received two perforator flaps, a TDAP and an anterolateral thigh flap or deep inferior epigastric artery perforator (DIEP) flap. The remaining patient received three perforator flaps, two TDAP and an anterolateral thigh flap. Fourteen patients had an improved range of motion after reconstruction. All the flaps survived except in the case of four patients who suffered partial loss of a TDAP flap. In one patient, there was partial skin graft loss at the donor site. The mean follow-up was 17.2 months (range 6-36 months).

CONCLUSION

Ideal reconstruction of burn scar contracture yielding functional and aesthetic results involves complete removal of scar tissue and reconstruction. Depending on the extent of the defect, the TDAP flap, with its thin and pliable tissue and minimal donor site morbidity, may be the best option for reconstruction of burn scar contracture.

Deep Inferior Epigastric Flap Combined Bilateral-Anterolateral Thigh Flap for the Coverage of Both Lower Extremity Soft-Tissue Defect: A Case Report and a Literature Review

Background/Purpose

Anterolateral thigh perforator (ALTP) flap and deep inferior epigastric perforator (DIEP) flap have been advantageous over traditional myocutaneous flaps as they preserve the integrity of donor site muscles and minimize the damage and complication to donor site structures. Here, we reported the efficacy of free ALTP and DIEP in the repair of large skin area and soft tissue defects on both lower limbs after trauma.

Case Report

A 19-year-old female traffic accident victim presented with multiple open bilateral fractures to the lower extremities with joint dislocation, massive skin and soft tissue defects, and multiple soft tissue contusion. Wounds on both lower extremities were covered with VSD (Vacuum Sealing Drainage). The tibiofibular and ankle joints on both lower limbs were fixed using external fixators. DIEP and ALTP flap were performed at different times.

Results

After transfer, the vascular pedicle was anastomosed to the anterior tibial artery, posterior tibial artery, and the accompanying vein. After the operation, the donor site was directly closed and sutured. All flaps survived with a good appearance, leaving only a linear scar at the donor site.

Conclusion

This case shows that free ALTP and DIEP flaps are ideal for repairing large skin area and soft tissue defects in bilateral lower limbs after trauma.

Does muscle improve validated outcome measures in open tibial fractures? New insights from a cohort study of the anterolateral thigh flap (ALT) versus ALT-Vastus lateralis flaps

The benefits of the muscle in open lower limb fractures remain to be determined. This study compared statistically equivalent groups of open tibial fractures treated by free anterolateral thigh (ALT) flaps or ALT flaps incorporating muscle (ALT-Vastus lateralis/ALT- VL). Method and Results: Chang Gung Memorial Hospital, Taiwan, 2004-2008, 49 free flaps in open lower limb fractures (38 open tibial) were specifically reconstructed with free ALT or ALT-VL flaps. Risk factors for non-union: equivalent between the two groups, with no differences in smoking, steroids, diabetes, time to flap and the AO classification of soft tissue and bone injury. Comparison of union rates: no difference was noted between groups in the Radiographic Union Score in Tibial Fractures (RUST) at 3, 6, 9 and 12 months. The only factor significantly associated with non-union was presence of a SPRINT trial defined 'critical' bone defect with odds ratio 14.4 (95% CI 1.36 - 131.5), with no association with AO bone classification, flap type, comorbidity or flap size. Patient-reported outcomes: the ALT-VL group showed improved patient satisfaction (p = 0.01, Cohen's d = 1.1). Functional outcomes (Enneking score) were not statistically significant, but the ALT-VL group trended towards significance in function and skin quality domains. Conclusions: Based on the results of this study, one can conclude that the degree of bone injury (specifically a 'critical' defect) is of greater relevance than flap choice with regard to fracture consolidation. Muscle does not result in improvements to union, the speed of union or deep infection. However, better PROMs may be related to the inclusion of the muscle around the fracture site.

Sensory assessment of meshed skin grafts over free gracilis muscle flaps without nerve coaptation for lower extremity reconstruction

Background

Little is known about the sensate recovery of skin grafts over free non-neurotized muscle flaps. The aim of this study was to evaluate the sensitivity of free gracilis muscle flaps and meshed skin grafts without nerve coaptation.

Methods

Thirteen consecutive patients with a median age of 55 years (range, 21–70 years) who underwent lower extremity reconstruction between September 2014 and October 2016 were included. Complications, flap contour, skin perception, and sensate recovery were assessed.

Results

All flaps survived completely. In one patient, wound dehiscence and infection occurred 1 month after surgery. After a median follow-up of 14 months (range, 10–51 months), a satisfactory contour and skin perception were achieved. The Semmes-Weinstein (SW) monofilament test (154.8±22 g) and static two-point discrimination (2-PD) (12.6±0.7 mm) showed intermediate recovery compared to the surrounding site (41% and 76%, respectively). There was an intermediate correlation between flap size and sensate recovery (2-PD: r=0.27, P=0.36; SW test: r=0.45, P=0.12). Vibration sensation recovered to 60%, whereas thermal sensation remained poor (19% at 5°C and 25% at 25°C).

Conclusions

Finer sensation could be partially restored. However, thermal sensation remained poor.

Limb Salvage Using Combined Linking Perforator Free Flaps

Microsurgical free tissue transfer is the most effective method for extensive reconstruction of lower limb defects. The purpose of this report is to describe our experience of using microsurgically fabricated combined linking perforator flaps for one-stage reconstruction of extensive lower limb defects. Between April 2008 and November 2016, 16 cases of extensive lower defects were reconstructed using combined linking flaps. Of the patients, 10 were males, and the mean age was 45.3 years (range = 20-76 years). The flaps used were thoracodorsal artery perforator flaps together with deep inferior epigastric artery perforator flaps or anterolateral thigh flaps. There were no total flap failures; however, 3 anterolateral thigh flaps were partially lost and required skin grafts. One wound disruption healed conservatively. Donor site healing was achieved primarily without any dehiscence. The follow-up period was 15.4 months (range = 8-24 months). The use of combined linking perforator flaps for lower limb defects is uncommon; however, in cases of extensive limb defects these flaps can salvage limbs by means of one-stage operations.

The "nugget design": A modified segmental gracilis free flap for small-sized defect reconstruction on the lower extremity

BACKGROUND

Little attention has been given to the segmental free gracilis muscle flap supplied by secondary proximal pedicles. We introduce a technical refinement for small-sized three-dimensional defect reconstruction on the foot.

METHODS

Between November 2013 and August 2016, three patients with a mean age of 66 years (range 47-70 years) were included. A segmental gracilis free flap supplied by the most proximal secondary pedicle was harvested according to a modified "nugget design" to treat small-sized defects on the lower extremity requiring dead space reconstruction. Minor and major complications, sensitivity with Semmes-Weinstein monofilament test, soft tissue stability and patient satisfaction at final follow-up were recorded.

RESULTS

In one case, a segmental gracilis muscle was used for dorsal foot reconstruction after debridement of metatarsal phalanx I with osteomyelitis. In two cases, the segmental gracilis free muscle was harvested for defect reconstruction on the right plantar foot after excision of a melanoma. The first patient required revision after partial failure of the initial segmental gracilis free muscle flap. Overall, good results in foot function and a high degree of patient satisfaction was achieved (Likert scale 9.7, range 9-10) after a mean follow-up of 13 months (range 3-24 months).

CONCLUSIONS

Taken from the very proximal dorsal part of the gracilis muscle supplied by the most proximal secondary pedicle and leaving the vast majority of the muscle intact preserves the option to harvest a normal gracilis flap. This technique is especially suitable for small, three-dimensional defects on the lower extremity.

Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: What is the safest coverage? A meta-analysis

INTRODUCTION

Currently, increasingly reconstructive surgeon consider the failure rates of perforator propeller flaps especially in the distal third of the lower leg are too important and prefer to return to the use of free flap at first line option with failure rates frequently lower than 5%. So, we performed a systematic review with meta-analysis comparing free flaps (perforator-based or not) and pedicled-propeller flaps to respond to the question "what is the safest coverage for distal third of the lower limb?"

METHODS

This review was conducted according to PRISMA criteria. From 1991 to 2015, MEDLINE®, Pubmed central, Embase and Cochrane Library were searched. The pooled estimations were performed by meta-analysis. The homogeneity Q statistic and the I² index were computed.

RESULTS

We included 36 articles for free flaps (1,226 flaps) and 19 articles for pedicled-propeller flaps (302 flaps). The overall failure rate was 3.9% [95%CI:2.6-5.3] for free flaps and 2.77% [95%CI:0.0-5.6] for pedicled-propeller flaps (P = 0.36). The complication rates were 19.0% for free flaps and 21.4% for pedicled-propeller flaps (P = 0.37). In more detail, we noted for free flaps versus pedicled-propeller flaps: partial necrosis (2.70 vs. 6.88%, P = 0.001%), wound dehiscence (2.38 vs. 0.26%, P = 0.018), infection (4.45 vs. 1.22%, P = 0.009). The coverage failure rate was 5.24% [95%CI:3.68-6.81] versus 2.99% [95%CI:0.38-5.60] without significant difference (P = 0.016).

CONCLUSION

In the lower limb the complications are not rare and many teams consider the free flaps to be safer. In this meta-analysis we provide evidence that failure and overall complications rate of perforator propeller flaps are comparable with free flaps. Although, partial necrosis is significantly higher for pedicled-propeller flaps than free flaps, in reality the success of coverage appears similar. © 2016 Wiley Periodicals, Inc. Microsurgery, 38:109-119, 2018.

The vastus lateralis free flap for lower extremity gustilo grade III reconstruction

BACKGROUND

Orthopedic trauma patients with Gustilo grade III injuries to the distal third of lower extremity present challenges to optimum reconstructive management. There is no consensus on the ideal autologous tissue for transfer in large lower extremity defect reconstruction. We present a large case series utilizing the vastus lateralis (VL) free flap for lower extremity Gustilo grade III reconstruction.

PATIENTS AND METHODS

This is a case series of patients who underwent VL free tissue transfer for Gustilo grade III injuries. A total of 38 free tissue transfers were performed for lower extremity reconstruction, 19 of which were VL flaps. Mean interval between injury and reconstruction was 46 days (range 7-240 days).

RESULTS

The mean wound size was 11.37 cm x 11.42 cm and all cases underwent delayed reconstruction. Seven day flap viability was 100% and 30-day flap viability was 17/19 (89%). There were six complications: two hematomas requiring drainage, one flap dehiscence, one distal flap loss requiring a reverse saphenous vein graft extension, and two complete flap losses. Of the two failed flaps, one was attributed to heparin-induced thrombocytopenia and the other to venous congestion complicated by methicillin-resistant Staphylococcus aureus infection.

CONCLUSIONS

The VL free flap is a reliable and versatile flap that can be tailored and tangentially thinned to match the shape and size of a defect, and the long pedicle allows the surgeon to stay away from the zone of injury. This flap should be strongly considered for lower extremity reconstruction, especially in salvage operations for large defects. © 2015 Wiley Periodicals, Inc. Microsurgery 37:212-217, 2017.

Perforator Flap versus Conventional Flap

The introduction of perforator flaps represented a significant advance in microsurgical reconstruction. However, confusion has developed due to the erroneous belief that perforator flaps are different from conventional flaps. The concept of the perforator is not new, but is an idea that evolved from the conventional flap. In fact, some of the flaps used by microsurgeons were perforator flaps. The only difference is the anatomical level of the blood vessels involved; the perforator concept is focused on the distal circulation, so-called 'perforator'. Therefore, thinner sections of tissue can be taken from the conventional donor sites of myocutaneous flaps. With the use of perforators, there are no longer "flap of choice" for specific reconstructions, because conventional donor sites have become universal donor sites, enabling the harvesting of a variety of flaps. Moreover, depending on the surgeon's ability, any flap can be utilized as a perforator-based island flap whose source vessel has been completely preserved. Therefore, tissues can be efficiently customized and tailored into any configuration required for reconstruction. The application of perforator flap technique enables more precise dissection, and allows more selective harvesting of thinner flaps, which will expand options in reconstructive surgery. No doubt the technique will continue to evolve.

Flap reconstruction of the knee: A review of current concepts and a proposed algorithm

A literature search focusing on flap knee reconstruction revealed much controversy regarding the optimal management of around the knee defects. Muscle flaps are the preferred option, mainly in infected wounds. Perforator flaps have recently been introduced in knee coverage with significant advantages due to low donor morbidity and long pedicles with wide arc of rotation. In the case of free flap the choice of recipient vessels is the key point to the reconstruction. Taking the published experience into account, a reconstructive algorithm is proposed according to the size and location of the wound, the presence of infection and/or 3-dimensional defect.

Prophylactic chimera anterolateral thigh/vastus lateralis flap: preventing complications in high-risk head and neck reconstruction

PURPOSE

In high-risk head and neck cases treated with tumor resection and associated radical neck dissection, orocutaneous fistulas and wound breakdowns in the neck are relatively frequent and can have serious consequences, such as carotid blowout syndrome (CBS), the need for salvage reoperations, and prolonged recovery time. The authors present the application of a prophylactic chimeric anterolateral thigh (ALT) and vastus lateralis (VL) flap to prevent complications.

MATERIALS AND METHODS

A retrospective review was performed of a historical group (96 patients) of patients with head and neck cancer treated with tumor resection, radical neck dissection, and microsurgical reconstruction of the tumor site only and a prospective cohort (21 patients) in which a chimeric ALT-VL flap was used to simultaneously reconstruct the tumor site and sternocleidomastoid muscle to fill dead space and protect the carotid artery.

RESULTS

The rate of complications was higher in the historical group: CBS occurred in 4.1% and orocutaneous fistulas in 11.5% of patients; 5.2% of patients required major salvage surgery for a wound complication. In the cohort group, no CBS or orocutaneous fistula occurred and no major salvage surgical procedure was needed.

CONCLUSIONS

Prophylactic ALT-VL flaps in high-risk head and neck cancers provide adequate and long-lasting soft tissue coverage for the carotid artery, with minimal additional morbidity, and could be beneficial in preventing serious and life-threatening wound complications and the need for reoperation.