Microvascular Free Flap Surgery Research Articles

Improvised perioperative techniques to meet the challenges of microvascular free flap surgery

Deformities of the head and neck region after radical oncosurgery can have devastating effects on the appearance of the patient with significant impact on patients quality of life. Reconstruction of such defects continues to be an extremely demanding challenge for plastic surgeons who aim to restore form and function with minimal surgical morbidity. The purpose of this communications is to highlight the various interventions and the protocols that are adopted to decrease the free flap failure rate.

Role of heparin in microvascular free flap surgery in head and neck reconstruction

Background: Microsurgical reconstructions for free flap transfer have been highly successful applications in the past decades. Antithrombotic prophylactic agents, such as low molecular- weight heparin, aspirin and dextran have been routinely used for the prevention of microvascular thrombosis. Even though these agents are efficacious in microsurgery, some systemic morbidity is still reported. Methods: The present prospective study was conducted in the Department of Surgical Oncology, Regional cancer center, Pt. JNMC, Raipur (C.G.), India from the January 2014 to June 2015. Each patient was informed and consent was taken to participate in the study. Detailed clinical history and examination of the patients was recorded. All Investigations relevant to the study were done before the surgical procedure. Outcome of the surgery were noted. Data was compiled in MS Excel and checked for its completeness and correctness. Then it was analyzed. Results: During the study period, 20 microsurgery operations on 20 patients were performed. There were 17 male and 3 female patients. In all patients neck dissection was done and resective part was reconstructed with free flap. Out of 20 free flap 12 radial artery free flaps and 8 free fibula flap was harvested. Conclusions: The free flap technique is safe but involves a significant learning period and requires careful postoperative monitoring of the patient. Early intervention is important for the salvage of free flaps and for lowering the failure rate.

Potential Effect of Two Different Anaesthesia Techniques on the Activation of Hhv-6 and Hhv-7 Infection in Relation to Changes in Total Lymphocyte Count and Peripheral Immune Cell Distribution after Prolonged Microvascular Free Flap Surgery / Divu Atšķirîgu Anestēzijas Metožu Ietekme Uz Hhv-6 Un Hhv-7 Infekcijas Aktivāciju Saistībā Ar Limfocītu Skaitu Izmaiņām Un Perifēro Imūno Šūnu Sadali Pēc Ilgstošām Mikrovaskulārām Brīvo

Abstract Microvascular free flap surgery is a complex method of wound closure for large wounds. Tissue trauma, surgical stress and general anaesthesia are known immunosuppressors that may exacerbate postoperative infections. Beta-herpesviruses HHV-6 and HHV-7 are immunomodulating viruses highly prevalent in the population of healthy individuals, which can interfere with the function of the host immune system. These viruses can be reactivated in immunosuppressed conditions. The aim of this study was to monitor the potential effects of two different anaesthesia techniques - general anaesthesia (GA) and regional anaesthesia (RA) - on the activation of HHV-6 and HHV-7 infection in relation to changes in the total lymphocyte count and peripheral immune cell distribution after microvascular free flap surgery. We found significant increase in the frequency of active HHV-7 infection after surgery (p < 0.05) in the GA group. In the RA group changes were not significant. The activation of HHV-7 infection was associated with decrease in the total lymphocyte count post-operatively in patients from the GA group. The data of our study show that reconstructive flap surgery under GA is linked with more frequent postoperative lymphopenia, which is a potential post-operative immunosuppressor that probably triggers the activation of HHV-6 and HHV-7 infection

The outcome of microvascular free flap surgery with or without the use of postoperative heparin.

To determine the outcome of microvascular free tissue transfer with or without use of postoperative heparin in terms of flap viability and postoperative complications. Quasi-experimental study. Department of Plastic Surgery, King Edward Medical University, Lahore, from July 2010 to July 2012. Thirty eight patients requiring elective or emergency microvascular free tissue transfer were selected. Those with poly-trauma, previous failed free flap and re-anastomosis of vessels were excluded from the study. All anastomoses were performed by trained microvascular surgeons. Per operatively, Aucland test was performed to ensure anastomotic patency. Thereafter, patients were divided into two groups: in group A, heparin was not given postoperatively and in group B, heparin was given postoperatively. The flaps were monitored for signs of vascular compromise, viability or non-viability and complications of the procedure. Chi-square test was used to compare the distribution of qualitative variable in two groups. P-value less than 0.05 was considered significant. In group A, the number of viable flaps was 13 (81%) and non-viable flaps were 3 (19%). In group B the number of viable flaps was 11 (73%) and non-viable flaps were 04 (23%) [p = 0.68]. There was no significant difference regarding postoperative complications between the two groups (p > 0.05). Postoperative heparin does not appear to have an influence on the viability or complications of free flaps.

Anaesthetic management of micro vascular free flap surgery

Anaesthetic management of a microvascular free flap surgery requires a holistic approach from the anaesthesiologist to have a favourable post-operative outcome. We present a case report of the anaesthetic management of a 31 year old male patient undergoing a microvascular free vascularized flap reconstructive surgery. After 16 hours of surgery and general anaesthesia, the patient was promptly reversed with no complications. The free flap remained viable throughout the post-operative period and the patient was discharged home after 15 days.

Tips for GP trainees working in oral and maxillofacial surgery

Oral and maxillofacial surgery is a unique specialty in its requirements for degrees in both medicine and dentistry. The dental element, especially when on-call, cannot be ignored. Many of the clinical procedures that you may be expected to competently carry out, involve the oral cavity — a foreign, cavernous black hole to even the well-seasoned medic — and a high degree of manual dexterity. Skills and knowledge learned in previous rotations are not always transferrable. The language is different. Patients will complain of problems with their teeth. Don’t let this put you off — persevere, and a fascinating, elegant, and hugely varied specialty will embrace you. You will quickly become intimate with osteotomies, cranioplasties, tracheostomies, and mandibulectomies and converse in a tongue unknown to your hospital colleagues, using terms such as ‘Le Fort’, ‘Ludwig’s’, and ‘SOF syndrome’ with reckless abandonment. You will work with paediatric patients, older patients, toothy patients, and violent patients, both in the emergency and elective setting. Your days can fluctuate from reconstructing the polytrauma victims’ mid face and orbit to correcting cleft lip and palate deformity, to assisting/observing microvascular free flap surgery in a patient with extensive head and neck cancer. Enter with an open mind. Don’t be afraid to ask for help, and first and foremost, learn tooth number and notation. The following tips are designed to give the GP trainee who finds themselves in an oral and maxillofacial surgical job both a taster and a head start in the scope covered by the specialty. Enjoy.

Cardiac output monitoring to guide fluid replacement in head and neck microvascular free flap surgery—what is current practice in the UK?

Appropriate fluid balance is an important factor in the survival of free flaps, and recently there has been a shift towards more conservative fluid regimens. Several surgical specialties have made extensive use of the relatively non-invasive method of measuring cardiac output (CO) to optimise fluid balance during and after surgery, which has resulted in a shorter hospital stay, but little has been published in head and neck surgery. To ascertain its use in the head and neck we sent a postal questionnaire to the anaesthetic departments of 40 major head and neck units identified from the 2010 database of the British Association of Oral and Maxillofacial Surgeons (BAOMS). Questions were asked about the number of free flaps done in the unit each year, the monitoring of central venous and arterial blood pressure (and inotrope protocols), optimal target variables, and whether CO was monitored (with type of device). Thirty-two units responded (80%). While 26 units (81%) routinely monitored central venous pressure (CVP), CO was monitored in only 3 units (9%). There was a wide range of responses in relation to optimal variables and use of inotropes. As with other specialties, it is likely that CO monitoring will become widely used in head and neck reconstructive surgery. Not only does it enhance fluid optimisation, but it may also reduce hospital stay and morbidity. Appropriate clinical studies are urgently needed to evaluate its use in our specialty.

Reply: One versus Two Venous Anastomoses in Microvascular Free Flap Surgery

Sir: We thank Rozen et al. for their interest in our article and congratulate them on their article, which contributes additional data regarding the routine performance of either one or two venous anastomoses.1 In their article, they report a lower rate of venous congestion requiring reoperation in deep inferior epigastric perforator (DIEP) flaps performed with two venous anastomoses (n = 291) compared with DIEP flaps performed with one venous anastomosis (n = 273) (0 percent versus 2.6 percent, respectively; p = 0.006). The mean operative time for both operations was virtually identical (p = 0.57). They conclude that DIEP flap breast reconstructions should routinely include two venous anastomoses because of lower flap failure rates and equivalent operative times. Our findings support the practice of performing a single venous anastomosis in cases where two venae comitantes are present, based on superior blood velocity, theoretically decreasing the chance of thrombosis.1 Velocity and flow are often confused in the literature, but they are different. Low blood velocity (measured in centimeters per second), along with turbulence and intimal injury, results in thrombosis. These three conditions are commonly referred to as Virchow's triad, after the German pathologist Rudolf Virchow, who detailed the pathophysiology behind pulmonary embolism. Blood flow (measured in milliliters per second) represents the volume of blood entering and exiting an organ, or flap in this case. Both are critical to flap survival; in simplified terms, inadequate blood velocity results in thrombosis, whereas inadequate blood flow results in unsatisfactory tissue perfusion. As we acknowledged in the Discussion section of our article, the question of whether a second venous anastomosis of a separate system of veins, rather than a second anastomosis of a vein draining the same venous system (a second vena comitans), is needed to maintain adequate blood flow (not velocity) in some flaps remains unanswered by the data we have presented.2 The DIEP flap is an example of a flap that usually includes two systems of draining veins: a superficial system that empties into the superficial inferior epigastric vein, and a deep system that empties into the venae comitantes of the deep inferior epigastric artery. In their study, the vast majority (92.1 percent) of DIEP flaps that had two venous anastomoses were flaps that included one vein from the superficial system and one vein from the deep system, rather than two veins from the deep system. It is possible, then, that the difference in venous complications they noted was because some of the flaps that had only one venous anastomosis were not satisfactorily drained by a single venous system, which is a problem of flow rather than velocity. Therefore, our findings do not necessarily contradict the findings by Rozen et al. However, given the very low rate of venous complications they experienced in their series (1.2 percent of all flaps), a much larger sample would be required to obtain satisfactory statistical power to clarify the question of whether the problems they observed were problems of inadequate flow or inadequate velocity. In summary, we support performing a second venous anastomosis of a separate venous drainage system, such as the superficial inferior epigastric vein in the DIEP flap, when signs of venous insufficiency are present, as we suggested in the Discussion section of our article and as Rozen et al. described in the Methods section of their article. The only argument that we can see for performing two venous anastomoses of a single venous system (i.e., both venae comitantes of the deep inferior epigastric artery) is to have a “backup” vein should one of the veins thrombose, for example, because of imperfect technique, distal pedicle or recipient vessel injury, size mismatch, or awkward pedicle geometry with a risk of later kinking or twisting. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication or of the article being discussed. Matthew M. Hanasono, M.D. Ergun Kocak, M.D. Olubunmi Ogunleye, M.D. Craig J. Hartley, Ph.D. Michael J. Miller. M.D. Department of Plastic Surgery University of Texas M. D. Anderson Cancer Center Houston, Texas

One versus Two Venous Anastomoses in Microvascular Free Flap Surgery

One versus Two Venous Anastomoses in Microvascular Free Flap Surgery

One versus Two Venous Anastomoses in Microvascular Free Flap Surgery

The authors' goal was to determine whether one or two venous anastomoses results in superior blood flow through microvascular free flaps. During flap harvest, blood velocity was measured in each of two venae comitantes using Doppler ultrasonography. Next, one of the two veins was occluded with a microvascular clamp and blood velocity was measured in the open vein. The clamp was then removed and placed on the other vein, and blood velocity was measured in the first vein. The pedicle was divided and microvascular anastomosis of either one or two veins was performed. Venous blood velocity was then compared between flaps with one versus two venous anastomoses. Eighty-one free flaps were performed. Before pedicle division, the peak venous blood velocity in each of the two venae comitantes averaged 6.3±4.8 cm/second. When one of the veins was occluded, the peak venous blood velocity increased to 19.5±17.3 cm/second (p<0.00001). One venous anastomosis was performed in 69 flaps and two venous anastomoses were performed in 12 flaps. The mean blood velocity in flaps in which one venous anastomosis was performed was greater than the mean blood velocity in either vein when two venous anastomoses were performed (13.1±7.3 cm/second versus 7.5±4.3 cm/second, respectively; p=0.001). When one vena comitans is occluded, blood velocity in the second vena comitans increases significantly. Venous blood velocity is significantly greater after a single venous anastomosis than in either of two veins when two venous anastomoses are performed. These results argue against routinely performing two venous anastomoses.

Lymphedematous Arm as Donor Site for Radial Forearm Free Flap in Thoracic Reconstruction

Sir: Recently, an article by Chang and Kim was published describing a large study of the incidence of lymphedema after mastectomy and radiotherapy, and after breast reconstruction with autologous flaps.1 This problem is a concern for every breast surgeon and remains controversial in the field of reconstructive surgery.2 Obviously, the real issue is for patients, who often avoid reconstruction to avoid risks related to surgery or further demolitions.3 In this way, we suggest an alternative free flap. We found that fasciocutaneous flaps could represent a valid alternative to muscular free flaps4—which represents one of the best alternatives—with an easy surgical technique and less morbidity, particularly when the patient refuses a contralateral latissimus dorsi free flap as in our case. We submitted four mastectomized patients suffering from radionecrosis and lymphedema to thoracic reconstruction with a radial forearm free flap taken from lymphedematous arm, to preserve the healthy arm (Fig. 1, above). We used the traditional procedure. Despite the lymphedematous tissues, dissection and harvesting of the flap was carried out with no difficulty (Fig. 1, below). The radial forearm free flap was successful in all cases. Flaps demonstrated long-term survival with easier surgical technique and less morbidity, particularly when harvested using a lymphedematous arm, and no worsening of the lymphedema was verified after surgery (Fig. 2, above). Despite initial scepticism, no disadvantages that we expected occurred, including an unsightly donor-site scar and skin graft breakdown with tendon exposure. The quality of our results seems to be stable, because actually no recidivism was verified and all the patients could return to their daily activities (Fig. 2, below).Fig. 1.: (Above) Preoperative view of radiodermitic wound in the thoracoaxillary region, with area of severe cutaneous distress and fistula in the right lateral district, associated with arm lymphedema. (Below) One year after surgery, improvement of surrounding tissues is observed because of trophism caused by the flap.Fig. 2.: (Above) Intraoperative view of flap sculpting from right lymphedematous limb, subsequently transferred and micro-anastomosed by means of two end-to-side anastomoses to the ipsilateral brachial vein and artery. (Below) Donor site 12 months after surgical treatment.We have proved that the radial forearm free flaps performed on lymphedematous upper limbs represented an adequate therapeutic choice, ascertaining the following: Upper limb lymphedema should not to be considered an absolute contraindication to perform microvascular radial forearm free flap surgery. The donor site shows normal healing without pathologic scars. Skin grafts taken at the donor site were successful, and no complications arose, despite the presence of lymphedema. In all patients, a great improvement was obtained, characterized by pain release and reduction of thoracic constriction. The lymphedematous swelling of the flap provided expanded and reliable tissue,5 which demonstrates that lymphedema does not represent a contraindication, making this the most conservative surgical procedure. In addition, lymphedema is not worsened after surgery and seems to be reduced in the long term. In our opinion, the radial forearm free flap offers several potential advantages over other fasciocutaneous flaps and muscle flaps for mastectomized patients and patients affected by radionecrosis undergoing thoracic reconstruction: it provides a large amount of well-vascularized, thin, pliable soft tissue; it is easy to harvest; and it has large consistent vessels and a long pedicle, particularly when, performing it, a lymphedematous donor site is used, which provides expanded tissue. Luca Vaienti, M.D. Laura Masetto, M.D. Giovanni Palitta, M.D. Plastic Surgery Department Università degli Studi di Milano Policlinico San Donato San Donato Milanese Milan, Italy Michel Merle, M.D. Institut Européen de la Main Hôpital Kirchberg Luxembourg

Microvascular Reconstruction in Children—A Report of 46 Cases

: We report microvascular free tissue transfers in pediatric patients in a retrospective series. : Forty-six children were treated in collaboration between the departments of Pediatric Surgery and Plastic Surgery, Helsinki University Hospital between 1986 and 2004 for microvascular free flap surgery. Trauma, tumor resection, congenital malformation, meningococcal septicaemia, and scars caused the tissue defects. The mean follow-up was 50 months. : The overall success rate was 96%. Twenty-five free flaps were transferred to the lower extremity. The most used flap was vascularized fibula. Preoperative angiography or intraoperative anticoagulants were not routinely used. Early reoperations were needed in four cases due to hematoma and in four cases due to thrombosis or impaired blood flow. All attempts of reanastomosis lead to salvage of the flap. : In cases of severe tissue defects in pediatric patients, microvascular free flap reconstruction is a treatment of choice. A multicenter study for guidelines on preoperative assessment and antitrombotic therapy in pediatric microsurgery is warranted.

Intracranial Microvascular Free Flaps

Large acquired intracranial defects can result from trauma or surgery. When reoperation is required because of infection or tumor recurrence, management of the intracranial dead space can be challenging. By providing well-vascularized bulky tissue, intracranial microvascular free flaps offer potential solutions to these life-threatening complications. A multi-institutional retrospective chart and radiographic review was performed of all patients who underwent microvascular free-flap surgery for salvage treatment of postoperative intracranial infections between 1998 and 2006. A total of six patients were identified with large intracranial defects and postoperative intracranial infections. Four patients had parenchymal resections for tumor or seizure and two patients had posttraumatic encephalomalacia. All patients underwent operative debridement and intracranial free-flap reconstruction using the latissimus dorsi muscle (N=2), rectus abdominis muscle (N=2), or omentum (N=2). All patients had titanium (N=4) or Medpor (N=2) cranioplasties. We concluded that surgery or trauma can result in significant intracranial dead space. Treatment of postoperative intracranial infection can be challenging. Vascularized free tissue transfer not only fills the void, but also provides a delivery system for immune cells, antibodies, and systemically administered antibiotics. The early use of this technique when intracranial dead space and infection coexist is beneficial.

An experimental study to sterilize medicinal leeches

Leeches are widely used to treat venous congestion in microvascular replantation, free and conventional flap surgery, and traumatology. The leeches require to be in full contact with the wound sites and this results in the contamination of the host with the leech's bacterial flora. Empirical prophylactic antibiotic administration to the patient to eradicate the flora of leeches before the application might be reasonable. The aim of this study was to sterilize or at least to reduce the number of colonies of the bacteria on Hirudo medicinalis. The leeches were immersed in several antibiotic solutions and the final results were studied. However, we failed to completely eliminate the bacteria from all leeches, but statistically significant cleaning was obtained with the combination of ciprofloxacin and chloramphenicol. The immersion of leeches before application to the patient with the predetermined antibiotic agents regionally may be beneficial to prevent invasive infection of the patient.

A clinical audit on the effect of suction drainage on microvascular anastomosis

Introduction: There are reports that thrombosis in microsurgically anastomosed vessels occurred after the vessels were drawn into the suction drains. Aim: To study the effects of suction drainage on microvascular anastomosis. Patients and methods: The authors compared the proportion of complications in 77 patients who had suction drainage (n=45) or no suction drainage (n=32) with microvascular free flap surgery in the head and neck region. Ultrasonography and Doppler flow ultrasonography were performed on five more patients 3 days after the operation. Results: There were no significant differences between the two retrospectively evaluated groups for incidence of postoperative complications. Ultrasound in the prospective study group revealed that vessels were neither sucked into the suction drain nor displaced towards the drain. Conclusion: These findings contravened the reports of vessels being sucked into drains and therefore the clinical use of suction drainage in conjunction with microsurgery in the head and neck region is still advocated.

Complications in microvascular free flap surgery

The avoidance of complications in the performance of microvascular free tissue transfer begins in the conceptualization of both the ablative and reconstructive phases of a procedure. Even the most experienced microvascular surgeon will encounter a broad range of complex clinical and technical issues, both predictable and otherwise, that he or she will also come to recognize, pre-empt, and compensate for, in acquiring true expertise. The appropriate application of microneurovascular free tissue transfer techniques has allowed ablative surgeons to more radically (and often more effectively) resect advanced-stage and recurrent malignant disease. As such, the indications for this technique have broadened and our already complex technical tasks are being further tested as we refine and reapply the state-of-the-art. The ability to minimize and avoid complications is a critical part of advancing this technique, which has made one of the most profound contributions to patient care of any in the modern era of reconstructive surgery. The avoidance of complications in the performance of microvascular free tissue transfer begins in the conceptualization of both the ablative and reconstructive phases of a procedure. Even the most experienced microvascular surgeon will encounter a broad range of complex clinical and technical issues, both predictable and otherwise, that he or she will also come to recognize, pre-empt, and compensate for, in acquiring true expertise. The appropriate application of microneurovascular free tissue transfer techniques has allowed ablative surgeons to more radically (and often more effectively) resect advanced-stage and recurrent malignant disease. As such, the indications for this technique have broadened and our already complex technical tasks are being further tested as we refine and reapply the state-of-the-art. The ability to minimize and avoid complications is a critical part of advancing this technique, which has made one of the most profound contributions to patient care of any in the modern era of reconstructive surgery.

A prospective study of microvascular free-flap surgery and outcome.

Over a 6-month period, 23 members of the International Microvascular Research Group participated in a prospective survey of their microvascular free-flap practice. Data were recorded with each case for 60 variables covering patient characteristics, surgical technique, pharmacologic treatment, and postoperative outcome. A total of 493 free flaps were reported with a representative demographic distribution for age, sex, indications for surgery, risk factors, flap type, surgical technique, and pharmacologic intervention. Mixed effects logistic regression modeling was used to determine predictors of flap failure and associated complications. The overall incidence of flap failure was 4.1 percent (20 of 493). Reconstruction of an irradiated recipient site and the use of a skin-grafted muscle flap were the only statistically significant predictors of flap failure, with increased odds of failure of 4.2 (p = 0.01) and 11.1 (p = 0.03), respectively. A postoperative thrombosis requiring re-exploration surgery occurred in 9.9 percent of the flaps. The incidence of this complication was significantly higher when the flap was transferred to a chronic wound and when vein grafts were needed, with increased odds of failure of 2.9 (p = 0.02) and 2.5 (p = 0.02), respectively. There was a lower incidence of postoperative thrombosis when rectus/transverse rectus abdominis muscle (TRAM) flaps were used, where odds of failure decreased by 0.36 (p = 0.04), and when subcutaneous heparin was administered in the postoperative period, where odds decreased by 0.27 (p = 0.04). There was an overall 69-percent salvage rate for flaps identified with a postoperative thrombosis. Intraoperative thrombosis occurred in 41 cases (8.3 percent) and was observed more frequently in myocutaneous flaps or when vein grafts were needed (5.5 and 5.0 greater odds, respectively; p < 0.001) but was not associated with higher flap failure (2 of 41 cases; 4.9-percent failure rate). The incidence of a hematoma and/or hemorrhage was increased in obese patients and when vein grafts were needed [2.7 (p = 0.02) and 2.6 (p = 0.03) greater odds, respectively], whereas this complication was significantly decreased in muscle flaps (myocutaneous or skin-grafted muscle), in tobacco users, when a heparinized solution was used for general wound irrigation, and when the attending surgeon performed the arterial anastomosis (in contrast to the resident or fellow on staff) (p < 0.05 for each factor). With the multivariable analysis, many factors were found not to have a significant effect on flap outcome, including the recipient site (e.g., head/neck, breast, lower limb, etc.); indications for surgery (trauma, cancer, etc.); flap transfer in extremes of age, smokers, or diabetics; arterial anastomosis with an end-to-end versus end-to-side technique; irrigation of the vessel without or with heparin added to the irrigation solution; and a wide spectrum of antithrombotic drug therapies. These results present a current baseline for free-flap surgery to which future advances and improvements in technique and practice may be compared.

A Prospective Study of Microvascular Free-Flap Surgery and Outcome

A Prospective Study of Microvascular Free-Flap Surgery and Outcome

Microvascular free flaps in head and neck surgery.

This study is a retrospective review of 60 patients who had microvascular free flap reconstructions in the head and neck region. They were all performed over a 10-year period by a single surgeon. The series includes a wide range of flap types and analyses pre-operative risk factors for flap failure as well as complications and outcome. Smoking and advanced age did not appear to prejudice flap survival but peripheral vascular disease, cardiac disease and alcohol withdrawal were found to increase the likelihood of flap failure. The most frequent complications encountered were thrombosis of one of the anastomosis and haematoma. The most successful flap in terms of survival and function was the fasciocutaneous radial forearm flap. The literature is reviewed in relation to the general principles of microvascular free flap surgery and the results of this series are placed in context.

下肢外傷後の軟部組織再建法の検討

In extensive injuries of the lower limbs, skin closure is very difficult. At Fukuoka University Hospital, we examined 32 cases which had undergone reconstructive surgery involving skin and soft tissue defect of the lower extremity between June 1988 and August 1990. Patients include 24 males and 8 females whose mean age was 38.3 years. Causes: 12 cases involved in open fractures, 9 cases of softtissue injuries, 5 cases with chronic osteomyelitis, 3 in burn-ulcer victims, 2 ulcered from I. V. drip infusion, and 1 involved in a skin flap donor site. Reconstruction methods varied from fascio-cutaneous flaps in 15 cases, including cutaneous arterial flaps and septo-cutaneous. 12 cases had split thickness skin grafts. 6 cases were treated with conventional local skin flaps. 3 cases had micro-vascular free flap surgery. One case had cross leg flap. Postsurgical complications included partial skin necrosis in half of the conventional local skin flap method cases, necessitating another operation. One of the three free flap method cases slough totally due to thrombosis of the anastomosis side of the vein. Only one of the 15 fascio-cutaneous flaps suffered from partial necrosis. We concluded that the most convenient, most successful, fastest healing, and safest method is the fasciocutaneous flap method.