Lower limb reconstruction with bone free flaps: experience of 25 cases

Bone structure is fundamental for the function of the lower limbs—orthostatism and locomotion. Before the technical evolution observed in the last two decades, many extremities that are saved now were amputated in the past. Lower limb bone defects are generally associated with complex traumatic lesions and constitute a permanent reconstructive challenge. The management of this kind of defect requires a multidisciplinary approach involving plastic and orthopedic surgeons. The bone free flaps are a very important and technically exacting tool for lower limb bone reconstruction. We present and analyze our experience in 25 traumatic cases where we used 17 fibula free flaps and 2 iliac crest free flaps for tibia and talus reconstruction; 5 fibula free flaps for femur reconstruction; and 1 antebrachial radial osteocutaneous free flap for first metatarsal reconstruction. We registered 88% of success (three flap necroses—12%) with good bone integration and good functional recovery. Lower limb bone reconstruction is a long and tortuous stair whose success depends not only on the multidisciplinary surgical team but also on the patient's cooperation and determination     

Our experience in lower limb reconstruction with perforator flaps

The application of Taylor's concept about body angiosomes, referred to tissue transfers, has meant that the development of the perforator flaps and muscles is no longer needed as a carrier of skin flap vascularity. In this paper, we revise 59 lower limb reconstructions with local and free perforator flaps performed in the last 5 years, and a basic reconstructive algorithm is also suggested to help with the management of the lower limb soft tissue reconstruction with perforator flaps. The advantages of the perforator flaps are (1) muscles and their function are preserved; (2) the main vascular trunks are spared; (3) it is possible to make a more specific reconstruction, replacing "like with like" (even performing compound or chimeric flaps); (4) the donor site can often be closed primarily; (5) the general morbidity is reduced; (6) a better cosmetic result can be achieved.     

Lower limb reconstruction in children using expanded free flaps

Controlled expansion is a technique that increases the area of local tissue available for reconstruction. An extension of this is to expand free flaps prior to elevation, thereby increasing their area. This has been particularly useful in children where there may be insufficient tissue available at free flap donor sites. Four children have had extensive cutaneous defects of the lower limb reconstructed with expanded parascapular free flaps. Measurements indicate an approximate doubling in skin area. There has been normal growth of the affected limbs and there has been no donor site morbidity. Apart from small areas of narrow marginal necrosis at the tip of the flaps in the first three cases, which were of no consequence, healing at the recipient site was complete.     

Thumb reconstruction by free sensory flaps from the foot using microsurgical techniques

Four types of thumb reconstruction using microsurgical technique were performed in 23 cases; the dorsalis pedis flap, hemipulp (first web space) flap, wrap around flap, and toe-to-thumb transfer. The selection of which free sensory flaps should be used for thumb reconstruction is discussed. The selection of sensory nerves to be sutured as the donor and recipient nerves is based on the results of restoration of sensibility after free sensory flap transfers.     

Use of antioxidant defense of tissues in free microsurgical transplant of complex-composite flaps]

In experiment on 25 epigastric muscular flaps of rabbits the possibilities of the flap tissues damage prophylaxis in the ischemia period were studied up as well as their defense from peroxidal and the free-radicals oxidation of the membrane phospholipids in the reperfusion period. There were noted suppression of the lipid's peroxidation processes, the raise of the flap's tissues antioxidant defense, the cellular and subcellular membranes stabilization with preservation of the vessels endothelium integrity after preliminary intraarterial infusion of the lipin, unithiol, ascorbic acid and isoptin mixture into the flap. The data obtained witness the perspective of the studied preparations application during microsurgical transplantation of composite complexes of tissues.     

Use of muscle free flaps in lower limbs reconstruction in children

A series of 12 muscle free flaps was performed from 2000 to 2005 in 11 children 3 to 15 years of age (mean: 10.6): seven serratus anterior, four latissimus dorsi and one rectus abdominis. The defects (acute or as a result of sequelae) were always located in lower limbs: seven in feet, three in the lower third of the leg and one in the knee. None of the children was re-operated within 72 hours. Total necrosis due to venous thrombosis occurred at Day 5 in one case. After mean follow-up of 2.5 years (minimum: 1 year), the flaps show good integration. Functional or esthetic sequelae are considered acceptable by the health-care team as well as the children's parents. No repercussions on growth have been observed. Our series confirms the results of previous studies, indicating that free flaps should be part of the therapeutic arsenal in pediatric surgery.     

Free groin flaps in microsurgical reconstruction of the extremity

The authors performed free groin flap transplantation in 36 patients with extensive soft-tissue injury of the extremities. In each case, the vascular anatomy of the groin flap was analyzed during the operation. The anatomic classification of the superficial circumflex iliac artery according to its origin was as follows: a common origin with the superficial inferior epigastric artery in 15 cases (39.5 percent); an isolated origin and absent superficial inferior epigastric artery in 14 cases (36.8 percent), a separate origin in three cases (7.9 percent), and an origin from the profunda femoral artery in six cases (15.8 percent). These results are similar to those reported previously. The overall success rate was 72.2 percent. The success rate was better in the upper extremity (100.0 percent) than in the lower extremity (65.5 percent). Free vascularized groin flap transplantation is a suitable procedure for the one-stage reconstruction of severe soft-tissue injury, especially in the upper extremity.     

Microvascular free tissue transfer in reconstruction of the lower limb.

Reconstruction of the lower extremity using microvascular free tissue transfer has been adopted as a routine procedure since the 1980s. Success rates in overall free tissue transfer are now as high as 98%. In the lower limb, however, the failure rate has been reported to be as high as 15 to 20%. A review of 50 consecutive microvascular free flaps to the lower extremity was carried out in the Ulster Hospital Belfast. The indication for surgery, the flap type, the recipient vessel, re-exploration rate, complication rate, success rate and the changing pattern in management during the first six years of a single consultant's practice was assessed. Six patients (12%) were re-explored for anastomotic complications or haematoma. Thrombosis of the arterial anastomosis was noted in one case, venous thrombosis in two and haematoma under the flap in the remaining three cases. Salvage was successful in four cases, thus producing an overall success rate of 96%.     

The reconstruction of the oral and maxillofacial defects with free vascularized flaps and microsurgical anastomoses

The reconstruction of the oral and maxillofacial defects is difficult, because of the high specialisation of the tissues. In cancer resection, the post-operatory defects are quite important, because of the oncological principle of assuring free margins. The free flap is a modem and nowadays very used method in oral and maxillofacial reconstruction, after the removal of the malignant tumors with this localisation. These flaps are indicated for large defects, when the reconstruction with local or regional flaps is not possible. The wide variety of the raised tissues allows better results, making them the flaps of choice for large defects of the lip and cheek. The main advantages are related to the tri-dimensional extension of the free margins, assuring the quality of life and allowing early initiation of the radiotherapy in oncological patients.     

Muscle and myocutaneous flaps on the lower limb

Defects of the lower limb can be repaired in several ways and a very satisfactory closure can be obtained using muscular and myocutaneous flaps. The soleus muscle, both heads of the gastrocnemius muscle, the peroneus brevis muscle and the flexor hallucis longus muscle can all be used, the choice depending on the site of the defect.