Skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage

Alexandra Kovar,Shawn Diamond,Matthew L Iorio

doi:10.20517/2347-9264.2019.09

Abstract

Aim: Free tissue transfer is essential for extremity reconstruction following traumatic injuries, oncologic resection, and diabetic complications. However, given the circumferential shape of the arm and leg, a small amount of ongoing edema can prevent a tension-free closure. Additionally, intraoperative thrombosis, vascular disease can lead to proximal exposure of the pedicle or vein grafts. This study evaluates the outcomes of microvascular transfers that utilized a skin graft for closure over the pedicle, in comparison with a matched cohort with a tension-free primary closure.

Highlights

Extremity reconstruction after trauma, oncologic resection, and diabetic complications often requires free tissue transfer to provide soft tissue coverage of bone, vessel, and nerve
The two cohorts were comparable in age, gender, BMI, and co-morbidities, excluding renal disease which was present in 40% (n = 4) of skin grafted group compared to 6.5% (n = 4) in the primary closure group
As per the principal, a tension-free closure is paramount to preventing tissue complications including direct compression of a microvascular pedicle

Summary

Introduction

Oncologic resection, and diabetic complications often requires free tissue transfer to provide soft tissue coverage of bone, vessel, and nerve. The circumferential shape of the arm and leg, joint surfaces, motion, tendon glide and potential for weight bearing in addition to the relative lack of elasticity of injured soft tissue, provides unique challenges for a tension free closure. Appropriate flap design requires attentive preoperative planning toward the dimension and thickness of a given defect while taking into consideration the anastomotic location, pedicle lie, vector, tension, motion, tendon glide and potential for weight bearing. Ruddiness and tension can impact the survival of free flaps if pressure is applied over anastomoses. Additional factors such as intraoperative thrombosis, pre-existing vascular disease, or other perioperative patient risk factors can lead to proximal exposure of the pedicle or vein grafts[1,2,3]

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