A Comprehensive Approach to Lower Extremity Free-Tissue Transfer

Lee L.Q. Pu, MD, PhD, FACS

Disclosures

Plast Reconstr Surg Glob Open. 2017;5(2):e1228 

In This Article

Abstract and Introduction

Abstract

Background: The purpose of this study was to introduce a comprehensive approach to lower extremity free-tissue transfer and report the clinical outcome that has been achieved with this approach.

Methods: The comprehensive approach developed by the author includes patient selection, flap selection, selection of the recipient vessels, flap dissection, flap preparation, microvascular anastomosis, flap inset, immediate postoperative care, intermediate postoperative care, and further follow-up care. Each part of this approach has its own special considerations. In an 8-year period, 28 consecutive lower extremity free-tissue transfers were performed in 28 patients by the author. The clinical outcomes were recorded based on the success of free-tissue transfer, any reoperations related to the revision of microvascular anastomosis, and any partial or total flap loss during an 8-year follow-up.

Results: All 28 lower extremity free-tissue transfers were performed successfully. All patients were discharged home once they tolerated dangling. No reoperations were needed for revision of microvascular anastomosis. No total or partial flap loss was encountered. Overall success of free-tissue transfer to the lower extremity in this series was 100%.

Conclusions: An ideal outcome of free-tissue transfer to the lower extremity can be accomplished with this comprehensive approach developed by the author. With good surgical judgment, adequate microsurgical skill, step-by-step intraoperative execution, and a protocol-driven clinical practice, the reconstructive surgeon should be able to improve his or her success for free-tissue transfer to the lower extremity.

Introduction

With many recent advances in reconstructive microsurgery, a successful free-tissue transfer can often be achieved for soft-tissue reconstruction of the lower extremity.[1,2] Frequently, free-tissue transfer to the lower extremity may be the only option for limb salvage in patients with a complex traumatic wound.[3]

The overall success rate of free-tissue transfer to the lower extremity is significantly lower than to the head and neck or breast even from some of the best microsurgery centers in the country.[4–6] This may be due to several important factors; for example, massive edema of the leg is frequently presented after trauma. Abnormal or thrombogenic recipient vessels are a common problem secondary to peripheral vascular disease or traumatic injury. The acceptable success rate of microsurgical free-tissue transfer to the lower extremity is less than 95% in contrast with up to 98% for microsurgical head and neck reconstruction and up to 99% for microsurgical breast reconstruction by some of high-volume centers. The failure of free-tissue transfer to the lower extremity remains relatively common compared with free-tissue transfer to the head and neck or breast.[4–6] Therefore, free-tissue transfer to the lower extremity for limb salvage is still challenging to many reconstructive surgeons.[7]

The purpose of this report was to introduce a comprehensive approach developed by the author for free-tissue transfer to the lower extremity. The clinical outcome with use of this comprehensive approach has also been reported. It becomes clear that the clinical outcome of free-tissue transfer to the lower extremity can be improved with this approach.

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