Reconstructive strategies for lower one-third leg soft tissue defects

Abstract

Background: Despite recent technical advances, reconstruction of lower third of leg wounds with soft tissue defects remains a challenge to the Plastic Surgeon. This is due to the inherent anatomical and structural configuration, including the limited vascularity of the skin of the lower third of the leg. Maintaining maximal function without compromising the aesthetic appearance of the leg is the goal of reconstruction.Methods: This was a retrospective study conducted in the Department of Plastic Surgery, KIMS Hospital, Bangalore, from January 2016 to January 2018. Patients with soft tissue defects involving lower third of leg requiring flap cover were included in the study. Orthopedic intervention was done as required. All patients underwent loco-regional or free flap cover as clinically indicated. Outcomes were studied.Results: Total of 20 patients were included in the study. Most common presentation was due to road traffic accidents (RTA). Right leg was involved in 12 cases and left in 8 cases. Fracture was present in 7 cases, exposed bone without fracture in 11 cases, exposed tendons alone in 1 case and exposed implants in 1 case. 3 Patients required orthopaedic intervention along with the flap procedure, and 4 had already undergone orthopaedic stabilisation. Most commonly performed procedure was muscle flap (45%), followed by perforator-based fascio-cutaneous flap (25%). No major complications were observed in the post-operative period.Conclusions: Lower third of leg reconstruction is a challenge, but a wide variety of options ranging from loco-regional to free flaps can be employed, depending on the situation. In present study, various types of flap cover were adopted to cover the lower-third of leg defects, depending on the nature of the wound. Present study delineated that muscle flaps - particularly the reverse hemi-soleus flap, are an ideal flap for lower third of leg defects with fracture site exposed and wound infected. Local muscle flaps have the advantage of being single-staged, faster to perform and technically easier, compared to free flaps, which have long been considered the gold standard.