Elective spare parts free flap—calcaneal fillet of foot flap

Severe lower limb trauma with significant soft tissue injury can be managed with reconstruction or, if this is impossible, amputation. If amputation is considered, below-knee amputation preserving limb length is optimal for long-term functional outcome. At times, soft tissue/bony injury can limit the ability to preserve limb length, particularly with proximal tibial injuries. We present a case of elective below-knee amputation where leg length and adequate soft tissue coverage was only possible by using an osteocutaneous fillet of foot and lower leg spare parts free flap, maintaining the tibial nerve pedicle for sensation and the posterior tibial artery for vascularity of the nerve. The procedure was technically challenging and required follow-up debulking operations. However, the technique provided the significant advantage of immediate sensation of robust glabrous distal stump cover and optimising leg length to enhance functional outcome.     

Emergency knee joint salvage utilizing a free musculofasciocutaneous flap based on the anterior tibial artery: case report

A young adult male presented with a traumatic amputation at the upper third of his left leg and an extensive soft tissue loss around his left knee. A free musculofasciocutaneous flap was elevated on the anterolateral part of the amputated segment and transferred to the soft tissue defect around the proximal left tibia in order to avoid an above-knee amputation. The entire flap depends on the anterior tibial artery for its blood supply. The anatomy of the flap is outlined. The importance of the musculocutaneous blood supply as well as the presence of an extensive fascial component make the flap very reliable. An 18-month follow-up period showed a uniformly well-contoured soft tissue coverage and an optimal functional result.     

Flow-through anterolateral thigh flap reconstruction as a salvage procedure

The anterolateral thigh flap is a very suitable flap to serve as a flow-through flap. It has a large, long pedicle and a large size skin island that can provide adequate soft tissue coverage. One-stage coverage and revascularisation can be achieved using the concept of flow-through circulation. The case presented describes a patient who suffered a major crush injury to the lower leg due to an accident with a fork-lift truck that led to an avascular lower leg. The anterolateral thigh flap was used as flow-through flap and amputation was avoided.     

Lower‐limb reconstruction with chimeric flaps: The quad flap*

Early soft‐tissue coverage is critical for treating traumatic open lower‐extremity wounds. As free‐flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free‐tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower‐extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft‐tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft‐tissue loss. In case 1, a 51‐year‐old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53‐year‐old man sustained a right tibia plateau fracture with large soft‐tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft‐tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long‐term complications in either case. Both patients achieved adequate soft‐tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad‐flap technique is promising for reconstructing the lower extremity.     

Free fillet flap application to cover forequarter or traumatic amputation of an upper extremity: A case report

Reusing tissue of amputated or unsalvageable limbs to reconstruct soft tissue defects is one aspect of the “spare parts concept.” Using a free fillet flap in such situations enables the successful formation of a proximal stump with the length needed to cover a large defect from forequarter amputation without risking additional donor‐site morbidity. The use of free fillet flaps for reconstruction after forequarter and traumatic upper extremity amputations is illustrated here in a case report. A 41‐year old patient required a forequarter amputation to resect a desmoid tumor, resulting in an extensive soft‐tissue defect of the upper extremity. A free fillet flap of the amputated arm and an additional local epaulette flap were used to reconstruct the defect. At 9 months after the procedure, a satisfactory result with a very well healed flap was attained. Free fillet flaps can be used successfully for reconstruction of large upper extremity defects, without risking additional donor‐site morbidity. © 2015 Wiley Periodicals, Inc. Microsurgery 36:700–704, 2016.     

Composite forearm free fillet flaps to preserve stump length following traumatic amputations of the upper extremity

BACKGROUND: Replantation of traumatic upper arm amputations are usually contraindicated due to patient age, comorbid diseases, ischemia time, and/or avulsion of proximal structures. Stable soft tissue coverage preserving proximal stump length and critical joints is required to prevent loss of limb function and aid in prosthetic fitting and comfort. The use of free fillet flaps from the amputated limb is well documented for lower-extremity amputations but has only recently been reported for upper-arm amputations involving distal humeral or elbow wounds or following radical upper-arm tumor resections. Furthermore, these described free fillet flaps were fasciocutaneous rather than composite flaps. Composite free fillet flaps from the amputated upper arm utilizing the flexor muscles adjacent to the vascular pedicles is not well described or documented. METHODS: Eight upper-extremity, composite, free fillet flaps were performed to cover proximal humeral and shoulder defects secondary to upper-arm traumatic amputation from July 1995 to May 2005 on 7 males and 1 female. A retrospective chart review was completed, and information collected included the age of patient, gender, date of injury and surgery, amputation site, mechanism of injury, ischemia time, type of fillet flap, donor and recipient vessels, flap sensation, flap survival, and number of complications. RESULTS: All upper-arm amputations were trauma related (100%) and secondary to industrial accidents (4), motor vehicle and motorcycle accidents (2), fall (1), and train (1). Patient age ranged from 16 to 62 years and polytrauma was noted in 50%. Procedures included 6 composite free fillet flaps and 2 radial forearm free fillet flaps, with 4 (50%) sensate. Sensory nerves included the medial (3) and lateral (2) antebrachial cutaneous nerves attached to median proximal nerve stumps. Ischemia time ranged from 280 to 630 minutes. All flaps survived and 2 (25%) complications occurred in 1 patient. Subjective and protective sensation was observed in each neurorrhaphy; however, no confirmatory tested was used. CONCLUSION: Immediate soft tissue coverage using composite free fillet flaps from amputated limbs can be successful, with few complications, and preserves limb length while maximizing available tissue. Furthermore, including flexor muscle belly adjacent to the vascular pedicles provides additional coverage and a well-vascularized composite flap to aid in prosthetic fitting and comfort.     

Free tissue transfer in reconstruction following soft tissue sarcoma resection

Background: Radical surgical resection remains the single‐most important treatment in the curative multimodal therapy of soft tissue sarcomas. Refinements in surgical techniques have resulted in the development of function preserving approaches increasingly avoiding limb amputation. Patients and methods: The records of all patients (n = 34) who underwent microsurgical soft tissue coverage subsequent to primary resection of soft tissue sarcoma of the upper or lower limb from 1999 to 2009 are reviewed regarding postoperative complications, time until start of adjuvant radiation and functional outcome (Toronto Extremity Salvage Score, TESS). Results: Thirty‐four patients (range: 21–86 years) received a total of 35 free flaps. Complete tumor resection was obtained in 33 patients, one patient required re‐excision ultimately resulting in tumor‐free margin status (R0 resection). Major complications were encountered in four cases including one patient with complete flap loss requiring an additional free flap and three patients with partial flap loss requiring split‐thickness skin graft procedures. Minor complications were observed in three patients (9%). Extremity salvage could be achieved in 33 patients with adequate postoperative ambulation (TESS 84 ± 18) and adequate use of the upper extremity (TESS 80 ± 22). One patient underwent amputation. Mean time until start of adjuvant radiotherapy was 37 days (range 24–56 days). Conclusion: A synergetic center‐based interdisciplinary approach is crucial in therapeutical management of soft tissue sarcomas with the aim of R0 resection status and limb preservation. Plastic surgery contributes by offering microsurgical reconstruction using free tissue transfer, thus broadening surgical possibilities. This increases the chance of both adequate oncosurgical resection and limb preservation. © 2011 Wiley‐Liss, Inc. Microsurgery 2011.     

Heel Coverage Using a Distally Based Sural Artery Fasciocutaneous Cross-leg Flap: Report of a Small Series

One of the goals in the management of severe open injuries of the foot is to obtain adequate soft tissue coverage. In extreme conditions of pedal soft tissue loss, in patients who are not satisfactory candidates for local or free-tissue transfer, the cross-leg flap remains an option for surgical reconstruction. We present the results of 7 patients with multiple lower limb open fractures associated with ipsilateral degloving injuries, and/or secondary pressure ulcers of the hindfoot with exposure of the calcaneus, in which a distally based sural artery island fasciocutaneous flap, elevated from the contralateral leg and crossed to the injured side, was used to repair the soft tissue defect of the recipient heel. All of the flaps survived and the soft tissues healed uneventfully, thereby providing satisfactory and stable coverage of the calcaneal tuberosity. To the best of our knowledge, this is the first report in which this technique has been used to repair hindfoot soft tissue defects associated with complex bone and vascular injuries of the lower limb in polytrauma patients. Level of Clinical Evidence: 4.     

Distal revascularization and microvascular free tissue transfer: an alternative to amputation in ischemic lesions of the lower extremity

Most lower extremity amputations result from complications of diabetes and arterio-sclerotic occlusive diseases below the inguinal ligament. Improved limb salvage has been achieved by an aggressive approach to distal revascularization in the severely ischemic lower extremity. There remains, however, a high incidence of amputation resulting from progression of the ulceration or gangrene into deeper and less well-vascularized tissues, such as tendon and bone. Even in the nonischemic extremity, such wounds rarely heal without flap coverage. Microvascular free tissue transfers promote healing by providing coverage with healthy, nondiseased, well-vascularized tissue for these difficult defects. Successful free flap transfer requires a high-pressure recipient inflow vessel. In contrast to individuals with nonarteriosclerotic lesions, many individuals with nonhealing ischemic lesions have no acceptable artery demonstrated on high-resolution angiography to serve as a recipient vessel. Limb salvage has been achieved in four candidates for amputation utilizing distal revascularization followed by free tissue transfer coverage of the ischemic lower leg defects.     

Salvage of a through-knee amputation level using a free fillet of sole flap

A young adult male sustained a compound crural fracture with a 15 cm defect of tibia and fibula, and an extensive soft-tissue loss of the lower leg and knee joint. A free fillet of sole flap was raised on the amputated foot and transferred to the soft-tissue defect around the femoral condyles in order to prevent an above-knee amputation. Intact vascularisation and sensation of the flap were secured by microsurgical anastomoses of the popliteal and posterior tibial vessels and the sciatic and tibial nerves. The patient was rehabilitated rapidly with a prosthesis. At the 12-month follow-up, he demonstrated excellent ?foot”? sensibility, stable soft-tissue coverage of the stump, and an optimal functional result. © 1993 Wiley-Liss Inc.     

Soft tissue coverage of the hand with a free digital fillet flap

A free digital fillet flap was used to achieve soft tissue coverage of the ulnar border of the hand in a 38 year old man with an industrial fan blade injury to the dominant hand. The use of a digital fillet flap from an unsalvageable ring finger allowed for a one-stage procedure avoiding donor site morbidity or need for additional reconstructive surgery.     

Limb salvage of infected knee reconstructions for cancer with staged revision and free tissue transfer

Periprosthetic infections of oncologic reconstructions have an amputation rate between 37% and 87%. Eleven patients with an infected knee reconstruction following limb salvage surgery for cancer were treated with the staged protocol. All patients underwent prosthetic removal and implantation of an antibiotic-impregnated cement spacer, i.v. antibiotic therapy, repeat debridement and spacer change, and delayed prosthetic reconstruction and free tissue transfer. At the time of reconstruction, the median bone defect was 185 mm. The mean soft tissue defect was 112 cm2. Coverage was obtained with a free musculocutaneous flap. All limbs were spared without amputation or flap loss. The mean functional outcome as measured by the Musculoskeletal Tumor Society lower extremity score was 23 of 30. Infections of large prosthetic reconstructions about the knee can be salvaged successfully with repetitive debridement, staged prosthetic reimplantation, and free tissue transfer. Free tissue transfer improves the soft tissue envelope and allows restoration of joint motion. Level of Evidence: Case Series. Level IV.     

Analysis of the Risk Factors for Free Flap Necrosis in Soft Tissue Reconstruction of the Lower Limbs

Objective

Free flaps are widely used for the repair of soft tissue defects in the lower limbs, but there is still a specific rate of necrosis. Few clinical retrospective studies have analyzed the nontechnical risk factors for lower limb free flap necrosis. This study aimed to analyze the nontechnical causes of flap necrosis in lower limb soft tissue reconstruction in order to identify risk factors and improve the survival rate of free flaps.

Methods

Clinical data from 244 cases of soft tissue defects of the leg or foot that were repaired with a free flap from January 2011 to June 2020 were retrospectively analyzed. The flap results were divided into complete survival and necrosis groups. The patients' general information, smoking history, soft tissue defect site, Gustilo-Anderson classification, shock after injury, type and size of the flap, and time from injury to flap coverage were recorded. A logistic regression model was used to analyze the correlations between flap necrosis and possible risk factors.

Results

Of the 244 flaps, 32 suffered from partial or total necrosis, and 212 completely survived. Univariate analysis showed that age, smoking history, soft tissue defect site, and time from injury to flap coverage were significantly correlated with flap necrosis (p ≤ 0.2). Multivariate logistic regression analysis showed that moderate-to-severe smoking history (p < 0.001, odds ratio [OR] = 10.259, 95% confidence interval [CI] = 2.886–36.468), proximal leg defect (p = 0.006, OR = 7.095, 95% CI = 1.731–29.089), and time from injury to flap coverage >7 days (p = 0.003, OR = 12.351, 95% CI = 2.343–65.099) were statistically significant risk factors for flap necrosis (p < 0.05), and age was excluded (p = 0.666; p = 0.924).

Conclusion

The risk of flap necrosis was significantly increased when the soft tissue defect was located in the proximal leg, the time from injury to flap coverage was >7 days, and the patient had a moderate-to-severe smoking history. These three risk factors have an increased influence on flap necrosis and have guiding significance in predicting flap prognosis.     

An experimental model for soft-tissue coverage of the traumatized distal lower extremity: the distally-based gracilis flap

A model for regional muscle-flap coverage of experimental soft tissue defects of complex injuries of the rabbit lower leg is presented. This technique has provided reliable and generous coverage without the difficulty or risk of a free flap procedure, nor the limitations of other local flaps.     

Microsurgical free flap transfer to amputation sites: indications and results

A series of microsurgical free flap reconstructions to amputation stumps of the upper as well as the lower extremities was reviewed in 7 male and 2 female patients. Indications included preservation of length after trauma in 6 patients and cure of local infection in 2 patients. In 1 patient an extensive defect after resection of a recurrent shoulder sarcoma required use of a complete arm fillet free flap for tumor reconstruction. Microvascular free flaps used included four scapular flaps, two fillet flaps from the amputated extremity, one anterolateral thigh flap, and one lateral arm flap. Seven of 9 patients were fitted with a prosthesis and underwent occupational therapy resulting in ambulatory and improved functional status. Microvascular reconstruction is indicated in emergency settings as well as for elective reconstruction of amputation sites. Using uninjured "spare parts" of the amputated extremity should be considered. Elective reconstruction is performed preferably with free flaps based on the subscapular vascular system.     

穿支皮瓣移植在手指创面修复中的应用

目的 探讨穿支皮瓣游离移植修复手指皮肤软组织缺损的设计和手术技巧.方法 切取小腿前外侧、小腿内侧下部、小腿外侧血管穿支皮瓣以及远段骨间背血管蒂穿支皮瓣,移植修复手指小创面13例.结果 13例皮瓣全部存活,受区与供区的功能、外观均良好.结论 在肢体部位以皮穿支或轴型血管为蒂设计穿支皮瓣,游离移植修复手指创面,患者痛苦小、损伤小,创面能获得满意覆盖.这为手外伤修复提供了一种新的选择,对术者也提出了更高的要求.     

Pedicled foot fillet flap based on the tibialis anterior vessels: case report

A case of an 18-year-old male with extensive posterior and lateral soft-tissue loss of the lower leg is reported. There was a segmental defect of 20 cm in the tibialis posterior neurovascular bundle, and the injury was not considered reconstructable. There was extensive soft-tissue trauma to the posterior compartments of the leg, with an intact and well-perfused foot. A primary amputation was indicated. The foot was used as a fillet flap for tibial length preservation and optimal stump coverage. The foot fillet flap was pedicled on the tibialis anterior vessels, preserving the deep plantar, first dorsal metatarsal, and anterior communicating vessels. The postoperative evolution was uneventful, with successful prosthetic adaptation.     

The free fillet flap after traumatic amputation: a review of literature and case report

Severe, mutilating hand injuries present difficult reconstructive scenarios. Often in these cases, portions of the amputated tissue may be used for reconstruction of the remaining digits and hand using the spare parts principle. The free fillet flap follows the spare parts concept. A literature review of free fillet flaps for hand and forearm coverage is provided. We also present a case report of a multi-digit and dorsal hand free fillet flap for coverage of a traumatic metacarpal hand. This flap demonstrates the value of ingenuity in planning during emergent trauma reconstruction.     

Reverse sural flap cover within a ring fixator

The ring fixator is an ideal apparatus to treat infected gap nonunion of the tibia and to correct deformity in multiple planes. However soft tissue problems may arise during transport and at docking. Although various options such as free flaps, neurocutaneous flaps, fasciocutaneous flaps and cross leg flaps are available for flap cover, this is always done prior to application of a ring fixator. The versatility of the sural flap in terms of coverage of leg defects, ease of performing flap cover as well as its reliability and safety is well known. We describe an alternate way of treating soft tissue problems which occur at the lower third of the leg while being treated on an Ilizarov frame. We describe the surgical procedure followed in raising the flap and its anterior transposition within the Ilizarov frame in two patients.     

Extended distally based DMCA flap in combination with autologous amputate skin transplantation as a salvage procedure for ring avulsion injury

A 23-year-old male student presented to our clinic with a traumatic complex ring avulsion of his right dominant index finger. Clinical evaluation revealed a complete distal amputation of the DIP joint with a laceration of the soft tissue at the middle phalanx and a rupture of the FDP-2-tendon far proximally. We hereby present the patient’s clinical outcome after reconstruction with a distally based extended DMCA-II flap. To our own knowledge, this is the first report of an extended distally based DMCA flap for coverage of a class IVd ring avulsion injury in combination with autologous amputate skin transplantation.Level of Evidence: Level V, therapeutic study.