Reconstruction Of Lower Limb Defects Research Articles

Keystone perforator island flaps in the reconstruction of lower limb defects resulting from shrapnel and mine-explosive combat injuries. Case series

In the conditions of warfare in Ukraine, the question of providing medical services to injured civilian and military is especially relevant and severe. In plastic surgeons` professional activities, the task is to restore extensive and deep wound defects in a short term and with a high degree of damaged organ`s restoration, especially supporting function. In this article the authors describe their experience with local keystone perforator island flaps, which are used to reconstruct skin and soft tissue defects of the lower limbs caused by combat injuries.
 Patients and methods. The authors conducted a retrospective review of 49 keystone perforator flaps for 28 patients (26 men and 2 women) who received treatment in the clinic for bullet, shrapnel, and mine‑explosive injuries between 2014 and 2022.
 Results. In all cases, extensive wound defects were completely closed during a single‑stage surgical procedure, and the patients were discharged after recovery. Non‑critical complications required secondary sutures in two cases (4%), extending the duration of treatment by 6 days. The time spent in the operating room on the transposition of one flap ranged from 40 to 95 min (mean: 67 min).
 Conclusions. The findings of the study show that local keystone perforator island flaps are highly effective in the successful reconstruction of lower limb defects caused by combat wounds. The keystone perforator island flap technique requires basic preoperative preparation of the patient, is easy‑to‑use, and exhibits a fairly high level of reliability at the same time. In most cases, keystone perforator island flaps provide primary and single‑stage closure of a large defect in the thigh, in the area of the knee joint, and in the lower leg in the absence of secondary defects that are common at donor sites when alternative techniques are chosen.

Use of locoregional Perforator Flaps for reconstruction of lower limb defects: Our experience

BACKGROUND: Popularity of perforator flaps for lower limb reconstruction has increased due to multiple advantages. It gives replacement of tissues using ‘like-by-like’ principles.METHODS: From December 2018 to January 2020, 11 cases of lower limb reconstruction were operated using perforator flaps. Outcome was assessed in view of age distribution, duration of surgery, hospital stay, postoperative complications, patient satisfaction & cosmesis.RESULTS: Partial flap necrosis was noted as most common (three cases) postoperative complication in our study. Other complications were superficial epidermolysis, venous congestion & total flap loss which were managed conservatively except one case in which skin grafting was performed after debridement of totally necrosed flap.CONCLUSIONS: Perforator flaps are having relatively simple surgical technique & advantage of less donor site morbidity. Identification of various perforators in lower limb makes its use more feasible for lower limb reconstruction.

Best Local Flaps for Lower Extremity Reconstruction.

The ideal reconstruction of lower limb defects should replace like with like and minimize morbidity to the donor site, achieving the best possible esthetic and functional outcome. The goal is to obtain stable healing and to resume daily life in an efficient manner. Although the classical local flaps such as gastrocnemius, soleus muscle flap, and the reverse sural flap have allowed to achieve those goals, perforator flaps are now added on to the armamentarium in lower extremity reconstruction using local flaps. A perforator-based local flap, such as a propeller or keystone flap, has made reconstruction efficient while further reducing donor-site morbidity. This article aims to provide a useful review of the best available local flaps for lower limb defects.

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.

Quality of Life after Flap Reconstruction of the Distal Lower Extremity: Is There a Difference Between a Pedicled Suralis Flap and a Free Anterior Lateral Thigh Flap?

Background:Flap reconstruction of the distal lower extremity is challenging. Especially, the concept of perforator surgery has increased available surgical options. Although results are generally judged in terms of objective facts, patients-perceived quality of life has largely remained unexamined. The aim of the study was to compare quality of life after lower extremity reconstruction with pedicled and free flaps.Methods:Patients were evaluated retrospectively after reconstruction of defects of the distal lower extremity either with distally based adipofascial sural flap (pedicled reverse sural flap) or an anterior lateral thigh (ALT) flap. A specific questionnaire was developed to measure the patient’s quality of life, based on short form health survey-12, Dresden Body Image Score-35, Patient Health Questionnaire-4, and X-SMFA questionnaires with additional specific questions. Furthermore, results, secondary surgeries, and complications were analyzed.Results:Thirty-seven patients with reconstruction of lower limb defects treated with a pedicled reverse sural flap and 34 patients treated with an ALT flap were included in the study. There was no statistical significant difference in the overall satisfaction with the procedure in the long-term follow-up between both groups, but patients with ALT showed a higher satisfaction with the treatment in the initial postoperative period. Both groups demonstrated approximately similar results in the long term for self-acceptance and vitality.Conclusions:Although anatomic situation may dictate flap choice coverage with free flaps, a less-complicated flap is by no means regarded as an inferior treatment option in patient’s estimation. Despite the intuitive speculation that patients with more advanced reconstruction methods should have better function and subsequently higher quality of life, this assumption was clearly not supported by data in this study.

The Keystone Flap in Dermatology: Clinical Experience with 18 Patients

Introduction and objectivesThe keystone flap is a fasciocutaneous flap supplied by perforating arteries. It is used in dermatology to repair surgical defects in areas with low skin extensibility (the upper and lower limbs and the back). We review the clinical experience gained with keystone flap reconstruction at our hospital and report on the surgical outcomes. Material and methodsDescriptive retrospective study of patients with malignant skin tumors on the lower limbs who underwent keystone flap reconstruction. ResultsEighteen patients (mean age, 77.83 years) underwent keystone flap reconstruction using the Behan technique in 17 cases and the modified Moncrieff technique in one. Basal cell carcinomas accounted for 38.8% of the tumors excised, squamous cell carcinomas 33.3%, and malignant pigmented tumors 27.7%. Cardiovascular risk factors were observed in 72.2% of patients. Minor complications occurred in 38.8% of patients, and there were no cases of partial or total flap necrosis. ConclusionsWe consider the keystone flap to be a good alternative to other flaps and grafts for the surgical reconstruction of lower limb defects. The success rate was high, and the cosmetic and functional outcomes were good.

Aplicación del colgajo de keystone en dermatología. Experiencia clínica en 18 pacientes

Introduction and objectivesThe keystone flap is a fasciocutaneous flap supplied by perforating arteries. It is used in dermatology to repair surgical defects in areas with low skin extensibility (the upper and lower limbs and the back). We review the clinical experience gained with keystone flap reconstruction at our hospital and report on the surgical outcomes. Material and methodsDescriptive retrospective study of patients with malignant skin tumors on the lower limbs who underwent keystone flap reconstruction. ResultsEighteen patients (mean age, 77.83 years) underwent keystone flap reconstruction using the Behan technique in 17 cases and the modified Moncrieff technique in one. Basal cell carcinomas accounted for 38.8% of the tumors excised, squamous cell carcinomas 33.3%, and malignant pigmented tumors 27.7%. Cardiovascular risk factors were observed in 72.2% of patients. Minor complications occurred in 38.8% of patients, and there were no cases of partial or total flap necrosis. ConclusionsWe consider the keystone flap to be a good alternative to other flaps and grafts for the surgical reconstruction of lower limb defects. The success rate was high, and the cosmetic and functional outcomes were good.

Free Vascularized Fibular Graft Transfer in the Reconstruction of Defects for Premalignant and Malignant Musculoskeletal Conditions of the Femur in a Tertiary Care Setting in Pakistan: A Series of Six Cases.

ObjectiveTo determine the application, success and complications of the utilization of free vascularized fibular grafts (FVFG) in the reconstruction of lower limb defects after resection of primary lower limb musculoskeletal tumors.MethodologyThis descriptive retrospective case series analysis was conducted at Shifa International Hospital from January 2011 to January 2016. It included patients who had premalignant and malignant conditions of the lower limb and subsequently had the lesion resected followed by FVFG surgery. The data collected was to outline the demographic profile, clinical features, and post-procedure outcomes and complications.ResultsThere was a total of six patients. The mean age of the patients was 25.8 ± 11.8 years (range: 15-40 years). The patients presented with pain, swelling, inability to bear weight and/or restriction of movement at the joint. Postoperatively, one patient had proximal wound necrosis and one patient had a thrombus in the anastomosed vessels, both of which were managed successfully.ConclusionWith a success rate of 100% at the end of the six-month follow-up period, FVFG surgery is a reliable procedure that may be successfully carried out for musculoskeletal tumors of the lower limb with minimal complications.

Versatility and “flap efficiency” of pedicled perforator flaps in lower extremity reconstruction

The use of pedicled perforator flaps provides an alternative to free tissue transfer for lower limb reconstruction. We use computer-aided image analysis to investigate the versatility of pedicled perforator flaps for the reconstruction of lower limb defects. Between April 2007 and April 2011, a case series of 61 patients with wounds of the lower extremity from knee to ankle were reconstructed with pedicled perforator flaps. We performed 16 pedicled reverse-flow anterolateral thigh (RF-ALT) flaps, 8pedicled medial sural artery perforator (MSAP) flaps, 26 pedicled peroneal artery perforator (PAP) flaps, and 11 pedicled posterior tibial artery perforator (PTAP) flaps. Digital planimetry of defects covered was analyzed and the "efficiency" of each flap was calculated, which allowed the assessment of the merits of each flap in the management of lower limb defects. Flaps healed primarily in 82% of cases (50/61). Approximately 50% of the secondary donor sites required skin grafting. Complications requiring secondary surgery occurred in 18% (11/61) of the cases. Six required secondary skin grafting (10%). One RF-ALT flap was converted into a free flap, one PAP required arterial supercharging, and three pedicled RF-ALT flaps required venous supercharging. Image analysis showed that these pedicled perforator flaps could cover 75% of the surface area of the lower leg. The higher length of perforator allowed for greater "flap efficiency" and better versatility of tissue cover. Image analysis can be used as a modality to assess the versatility of individual flaps in the reconstruction of lower limb defects.

Perforator flaps for reconstruction of lower limb defects

Background: Reconstruction of soft tissue defects in the lower third of the leg remains challenging. Anatomical constraints limit the local options available for complex defects especially lower third of leg. Local flaps based on perforator vessels are raising interest in reconstructive surgery of the limbs. We present our experience with perforator flaps for reconstruction of soft tissue defects in the lower limb . Methods: The study was carried prospectively and 23 patients with lower limb defects treated with various perforator flaps (both elective as well as emergency) were included in the study. A hand-held Ultrasound Doppler was used preoperatively and intraoperatively to detect the perforator vessels . Results: Out of 23 patients, we witnessed partial flap loss in 1 and distal flap necrosis in 3 patients. 4 patients had minor complications which included infection, wound dehiscence and congestion of flap . Conclusions: Perforator flaps may represent a good alternative to the free flaps in the areas were other local reconstructive procedures are not possible. This is a versatile technique and with decreased donor site morbidity limited to a single body area. There is a specific like to like soft tissue replacement leading to a better cosmetic and reconstructive outcome. The main drawback of the perforator flaps however is the higher risk of venous congestion .

Cent cinquante-sept lambeaux pédiculés utilisés dans la reconstruction des membres inférieurs : étude rétrospective sur dix ans

The aim of this study was to review and present our experience with pedicled flap reconstruction of lower limb defects with particular reference to choice of flap, complications and pre-existing health disorders. A retrospective review of lower limb reconstructions by pedicled flaps was carried out by the plastic and reconstructive surgery unit at Marseille's hospitals from January 1st, 1997 to December 31st, 2007. This study evaluated patients satisfaction and complications rate. During 10 years, 152 patients had 157 local flap reconstructions of lower limb defects. General patients satisfaction was 94% with 80% good or very good results and 20% of medium results. There were 16 immediate complications with three total necrosis, four partial necrosis, six hematoma, and three infections. There were nine late complications including wound dehiscence and graft instability. There were 11 functional sequels and 40 aesthetic sequels secondary to flaps. The current study presented our experience with locoregional flap reconstruction of lower limb defects. Lower limb reconstruction used a lot of locoregional flaps which had their own advantages and disadvantages. Their indication depended on the fiability and quality of the donor site.

Reconstruction of Complex Ankle Joint Defects Using a Composite Free Anterolateral Thigh Musculocutaneous Flap with Vascularized Fascia Lata: A 20-Year Follow-Up

Sir: The reconstruction of complicated composite defects around the ankle is always a challenge for the plastic surgeon. With recent advances in microsurgical techniques, the free anterolateral thigh flap has emerged as one of the major resources for lower extremity salvage.1 We have attempted several techniques and now favor single-stage reconstruction of lower limb defects after open trauma using an anterolateral thigh myocutaneous flap with vascularized fascia lata. We report the case of a 17-year-old boy who sustained a car tire injury to his left foot, resulting in crush avulsion of the soft tissues, talofibular and calcaneofibular ligaments, and peroneus tendons, and partial loss of the fibula and talus. A 20 × 11-cm composite anterolateral thigh musculocutaneous flap including a 10 × 7-cm strip of vascularized fascia lata along with a cuff of vastus lateralis was harvested from the right thigh. The exposed ankle joint where the malleolar sclerotin was lacking was obturated by the vastus lateralis muscle of the flap. The fascial strip was rolled and interwoven to connect the peroneus musculotendinous junction and the lateral ankle ligament. End-to-end microvascular anastomoses were performed between the anterior tibialis vessels and the descending branch of the lateral circumflex femoral vessels. Most of the donor site was closed, and the residual area was covered by a split-thickness skin graft harvested from the opposite thigh (Fig. 1). The patient's postoperative course was uneventful. Two months postoperatively, the patient resumed his daily ambulating without any support, although a slight varus deformity of the left ankle was exhibited on physical examination. Three years postoperatively, the varus deformity had disappeared, and the patient could take part in physical training. Twenty years after the initial procedure, the patient was recontacted, and the function of the left ankle was evaluated by clinical examination. Although there was some loss of ankle activity, the patient did not have any problems with the stability of the joint and was sufficiently competent for his job (Fig. 2).Fig. 1.: A 17-year-old boy sustained a car tire injury to his left foot resulting in extensive crush avulsion (above, left). After débridement, a 20 × 11-cm composite anterolateral thigh musculocutaneous flap including a 10 × 7-cm strip of vascularized fascia lata was used to salvage the foot (above, right and below).Fig. 2.: Follow-up at 20 years revealed a well-contoured foot with acceptable activity of the ankle joint (above) and a narrow joint space with trauma-arthritic changes on the radiographic images (below).The reconstruction of combined defects including a large, deep defect of bone and soft tissue around the ankle is always clinically challenging and technically demanding.2 The use of traditional local flaps for reconstruction is limited, as these flaps only supply coverage of soft-tissue defects rather than preserving the stability and function of ankle joints.3 In contrast, the one-stage reconstruction associated with the anterolateral thigh flap offers many advantages to reconstructive surgeons, such as suitability for a two-team approach, rapid healing, high resistance to infection, and minimal donor-site morbidity.4 We favored the composite anterolateral thigh flap in this case because it meets most reconstructive needs for total ankle reconstruction as described above and has some other special advantages. First, in the case of wound infection, a musculocutaneous flap is safe because well-vascularized muscle tissue under the skin island prevents exposure of the joint and decreases the rate of infection after single-stage reconstruction. Second, in this case, the fascia lata was anchored to the distal and proximal remnants of peroneus muscles, which recovered the integrity and function of the evertors. More importantly, through the application of this composite flap, we successfully restored the ankle stability without arthrodesis, which would probably have resulted in additional postoperative complications for the patient. Twenty years postoperatively, although the radiographic image showed a narrow joint space with trauma-arthritic changes, the patient has achieved acceptable ankle power strength and range of motion (Fig. 2). In conclusion, the composite anterolateral thigh musculocutaneous flap with vascularized fascia lata represents an excellent option for covering complex defects around the ankle joint. The long-term functional and aesthetic results are good. We believe that this flap should be used as an alternative for reconstruction of extensive defects around the ankle. Kai Huang, M.D. Xiao-wen Zhang, M.D. Li-feng Shen, M.D. Qiao-feng Guo, M.D. Chun Zhang, M.D. Department of Orthopedics Tongde Hospital of Zhejiang Province Health Bureau of Zhejiang Province Hangzhou, Zhejiang, People's Republic of China DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Postoperative monitoring of lower limb free flaps with the Cook–Swartz implantable Doppler probe: A clinical trial

Free flaps to the lower limb have inherently high venous pressures, potentially impairing flap viability, which may lead to limb amputation if flap failure ensues. Adequate monitoring of flap perfusion is thus essential, with timely detection of flap compromise able to potentiate flap salvage. While clinical monitoring has been popularized, recent use of the implantable Doppler probe has been used with success in other free flap settings. A comparative study of 40 consecutive patients undergoing microvascular free flap reconstruction of lower limb defects was undertaken, with postoperative monitoring achieved with either clinical monitoring alone or the use of the Cook-Swartz implantable Doppler probe. The use of the implantable Doppler probe was associated with salvage of 2/2 compromised flaps compared to salvage of 2/5 compromised flaps in the group undergoing clinical monitoring alone (salvage rate 100% vs. 40%, P = 0.28). While not statistically significant, this was a strong trend toward an improved flap salvage rate with the use of the implantable Doppler probe. There were no false positives or negatives in either group. One flap loss in the clinically monitored group resulted in limb amputation (the only amputation in the cohort). A trend toward early detection and salvage of flaps with anastomotic insufficiency was seen with the use of the Cook-Swartz implantable Doppler probe. These findings suggest a possible benefit of this technique as a stand-alone or adjunctive tool in the clinical monitoring of free flaps, with further investigation warranted into the broader application of these devices.

Reverse sural artery flap for distal lower extremity defects

Traumatic and various dermatological conditions resulting in skin and subcutaneous tissue loss on the lower limb cause a therapeutic challenge for the dermatological surgeon, because this anatomical location lacks adequate skin laxity and has limited local soft tissue, especially around the heel. In this report, we present our experience with the reverse sural artery flap on seven patients. The soft tissue defect was traumatic in two patients. We also treated three diabetic patients. There were no immediate or late surgical complications in four cases; flap and donor site healing was uneventful. The remaining three cases were diabetic, and all presented with the following complications: rejection of split skin graft at donor site, infection at the flap border and superficial flap necrosis. The flap necrosis was concluded to be at least in part due to the patient's noncompliance with postoperative measures. We conclude that the reverse sural artery flap is a satisfactory alternative in the reconstruction of lower limb defects, but we also feel that the importance of proper evaluation prior to surgery in terms of vascular impairment and patient compliance should be emphasized to ensure a successful surgical outcome.

Fascial feeder and perforator-based V-Y advancement flaps in the reconstruction of lower limb defects

The principle of the V-Y advancement flap has been used since its first description by Blasius (1848) for reconstruction of smaller defects. We wish to describe V-Y advancement flaps, the design of which includes distinct perforator or fascial feeder vessels, which may originate from periosteum, muscle, cutaneous nerve or from large tendon sheaths. These flaps are planned in an oblique manner when there is a defect over the anterior, antero-lateral or antero-medial aspect, and in a vertical manner when there is a defect over the posterior aspect of the leg. The main advantage of this design is the ability to close the secondary defect primarily, allowing adequate cover of the defect, particularly in the pre-tibial region, without the unsightly divot left by a split skin graft in this area. When the flap includes branches of the long saphenous nerve on the medial aspect, superficial peroneal nerve laterally or sural nerve posteriorly it results in a sensate flap, giving protection in this vulnerable area, which has previously not been possible. We describe 40 cases where perforator-based V-Y advancement flaps have been used to cover large defects of the lower leg following excision of malignant skin lesions and in selected trauma cases that do not involve degloving injuries. This technique allows adequate soft tissue cover in the pre-tibial area and around the ankle with excellent aesthetic results. The planning, operative technique and the results with case presentations have been described.

Latissimus Myocutaneous Free Flap in the Reconstruction of Lower Limb Defects—Three Clinical Cases

Latissimus Myocutaneous Free Flap in the Reconstruction of Lower Limb Defects—Three Clinical Cases