Upper extremity salvage procedure with flow-through free flap transfer taken from the amputated part

An alternative free flap technique in a patient presenting with an incomplete amputation in the right cubital region, resulting from a gunshot wound, is introduced. The defect area was repaired using a flow-through fasciocutaneous free flap, which, when following a cubical or popliteal region amputation, is a suitable option for revascularisation and salvage of the extremity. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:163–165 1998     

Amputation salvage with microvascular free flap from the amputated extremity

Microvascular surgery has allowed creative primary reconstruction using undamaged parts of amputated limbs as donor sites. We present a case of lower extremity below-knee amputation salvage with a free flap of heel, calcaneus, and soft tissues from the amputated lower leg, ankle, and foot supplied by the posterior tibial neurovascular bundle.     

Cross-leg free flap for emergency extremity salvage: case report

The use of a cross-leg free flap and consequent limb salvage was successfully performed in a 10-year-old boy with a compound open fracture of the tibia, involving extensive skin and soft-tissue loss. This method should be kept in mind, as it may sometimes, in an emergency situation, lead to lower-extremity salvage, as in the case reported.     

Upper extremity reconstruction using free SCIA/SIEA flap

The most suitable free flap alternative in upper extremity reconstruction has adequate and quality of tissue with consistent vascular pedicle. Free flap must provide convenient tissue texture to reconstruct aesthetic and functional units of upper extremity. Furthermore, minimal donor site morbidity is preferred features in free flap election. In our efforts to obtain the best possible outcome for patients, we chose, as a first priority, the free superficial circumflex inferior artery (SCIA)/superficial inferior epigastric artery (SIEA) flap over other free flap options for the soft‐tissue reconstruction of upper extremities. The authors retrospectively report the results of 20 free SCIA/SIEA flaps for upper extremity reconstruction during the past 3 years. Nineteen of 20 flaps were successful (95%): three required emergent postoperative reexploration of the anastomosis and one failed. Flap thinning (n = 4) was performed during the flap harvest, whereas some flaps were thinned with secondary debulking (n = 4). The functional and aesthetic results were evaluated as acceptable by all patients. Based on our results, a free SCIA/SIEA flap has the following advantages in soft‐tissue reconstruction of the upper extremity: (1) if necessary, flap thinning may be performed safely at the time of flap elevation and (2) flaps are harvested using a lower abdominal incision so that it causes minimal donor site scar. © 2009 Wiley‐Liss, Inc. Microsurgery, 2010.     

Lateral thigh free flap with flow-through vascular pedicle

The lateral thigh flap based on the second and third perforator of profunda femoris vessel has not become very popular. We describe a technique of flow-through pedicle for this flap. The flow-through technique makes this flap very simple to transfer. The flap was used successfully in 6 cases for reconstruction for defects in the leg and forearm. The flow-through pedicle is ideal for lower limb reconstruction. The anastomosis becomes very easy and safe, even if the recipient vessels are deep in the intermuscular septum. We had no flap failures. The flap has a very predictable anatomy. Large flaps from anteriolateral and posterior part of midthigh can be safely elevated. The flap can meet a variety of requirements as it can be thin skin-alone flap, a fasciocutaneous flap, or even a musculocutaneous flap. A simple pinch test gives a fair idea of expected flap thickness. The dissection requires strong retraction of the anterior thigh muscles, but the dissection is safe and simple. The donor-site morbidity is very minimal.     

Lower extremity salvage using a free flap associated with the Ilizarov method in patients with massive combat injuries

Nine patients with massive combat injuries of the lower extremities were treated with Ilizarov bone transport in conjunction with free muscle flap coverage. In 4 patients soft-tissue coverage was applied first, and distraction osteogenesis was initiated 4 to 6 weeks later. In 3 patients both methods were applied simultaneously, and in 2 patients soft-tissue coverage occurred after distraction. The bones healed well, and all flaps survived. The segmental defects ranged from 8 to 16.5 cm in greatest dimension. The total disability time from initial injury ranged from 16 to 25.5 months. In all patients, full union of the tibia was achieved, and no osteomyelitis occurred. However, in 2 patients the applied flap became depressed, necessitating another flap operation. Despite late treatment in all 9 patients, successful results were obtained. Maintaining the original length of the tibia and providing timely, definitive treatment offer the best outcome for repair of massive injuries of the lower extremities. The Ilizarov transport method, used in combination with muscle flap coverage, represents an effective therapy for repair of massive injury of the lower extremities.     

Upper extremity salvage using the tensor fascia lata flap: report of two cases

The tensor fascia lata pedicled flap was successfully used to salvage 3 severely injured upper extremities in 2 patients. Both patients had undergone 3 prior free tissue transfers without complete closure of their wounds. All 3 tensor fascia lata flaps (2 myocutaneous, 1 myofascial) survived entirely. We believe this flap offers a distinct advantage compared with the groin flap when pedicled flap coverage of the upper extremity is required.     

Use of latissimus dorsi flap pedicle as a T-junction to facilitate simultaneous free fibular flap inset in lower extremity salvage

Marjolin's ulcer is a very aggressive form of squamous cell carcinoma arising from chronic wounds or unstable scars. A resection margin of at least 2 cm with clear deep margin is required on removal. A 79-year-old male presented with chronic osteomyelitis of the left anterior tibial region with chronic ulceration. Biopsy revealed squamous cell carcinoma. The tumour, measuring 8 cm, was resected with surrounding unstable scar tissue including en bloc resection of the involved tibial bone, leaving the posterior cortex. Reconstruction was done with a fibular free flap from the contralateral side, but the pedicle length was too short to reach the anterior tibial vessels. To bridge the vascular gap, and to cover the soft-tissue defect, a latissimus dorsi free flap was harvested using the muscle-sparing method. The thoracodorsal vessels were used as an interpositional graft to anastomose the peroneal vessels of the fibular flap. The patient was ambulatory by 4 months, and complete bone union was seen after 6 months. During the 18-month follow-up period, there was no evidence of recurrence.     

Late salvage of a free TRAM flap.

We present the case of a patient with arterial thrombosis of a free TRAM flap 11 days after surgery. Initial salvage involved thrombectomy through an arteriotomy using a Fogarty catheter. Subsequent return to the operating theatre was necessary because of further vascular compromise. Thrombectomy was combined with flap thrombolysis and anticoagulation, and the flap remained viable at 6 months. Although rates of successful salvage vary, the literature indicates that flaps are rarely saved if signs of compromise present later than 2 days postoperatively. This case demonstrates that aggressive salvage may be successful even in cases of 'late' vascular compromise.     

Subscapular artery Y-shaped flow-through muscle flap: a novel one-stage limb salvage procedure

OBJECTIVES: Major tissue loss caused by the critical limb ischemia requires improvement of distal perfusion and cover of large tissue defects. We propose a new method, the y-shaped subscapular artery flow-through (Y-SCAFT) muscle flap using the subscapular artery that yields an arterial graft and a free muscle flap sustained by a collateral branch of this artery. This prospective study evaluated the feasibility of this technique and analyzed wound healing, graft patency, and limb salvage. METHODS: Between 2002 and 2007, 20 patients, mean age 64 years (range, 55-79 years), were treated with this technique. All presented with critical ischemia and major tissue loss, with exposure of the tendons, bones, or joint, and were candidates for major amputation. Revascularization and cover of tissue loss with the same Y-SCAFT anatomic unit was used for all patients. The distal anastomosis was performed between the distal branch of the Y-SCAFT and the pedal artery in 9, posterior tibial artery in 4, peroneal artery in 1, lateral tarsal artery in 3, and the plantar artery in 3. In four patients, the distal part of the arterial graft, including the anastomosis, was covered with the muscle flap because the tissue loss was nearby. The proximal anastomosis was performed between a leg artery and the arterial graft in 10 patients. A venous graft was necessary in 10 patients to extend the bypass proximally. RESULTS: One patient died during the postoperative period. Duplex control evidenced patency all the Y-SCAFT muscle flaps. Healing was achieved in all patients. Mean follow-up was 31 months (range, 6-58 months). No patients died during follow-up. One patient presented occlusion of the Y-SCAFT muscle flap and underwent amputated. One patient had major amputation despite a patent graft. At 2 years, leg salvage was 85%, patency was 94%, and survival was 94%. At the end of the follow-up, 17 patients (1 death, 2 amputations) had a patent graft, a viable muscle flap, wound healing, and a functional leg. CONCLUSION: We showed the clinical feasibility of the technique of Y-SCAFT muscle flap, which allows for revascularization and cover of major tissue loss with one anatomic unit. This method is particularly useful in selected cases with poor run-off and large ischemic lesions.     

The flow-through free flap in replantation surgery: a new concept

The concept of flow-through circulation in free flaps was previously described as a one-staged technique for cover and revascularisation of ischaemic traumatized extremities. This paper describes the practical use of the concept in replantation surgery. Two clinical cases of hand replants are presented in which an uninterrupted flow was established through the selected free flap.     

Flow-through arterialised venous free flap using the long saphenous vein for salvage of the upper extremity

We used two flow-through arterialised venous free flap transfers with the long saphenous vein to reconstruct major arteries and injured skin and soft tissues in the upper extremity. Operating time was reduced, only one donor site was used, and reconstruction of a long arterial defect (24-25 cm) was possible.     

New experimental flap model in the rat: free flow-through epigastric flap

This study describes a free flow-through flap model in the rat for use in the evaluation of the physiologic and hemodynamic characteristics of this type of flap in clinical practice. The rat is a preferred animal model because it is inexpensive, readily available, and reliable. There is no free flow-through flap model available for laboratory animals, although this model gained popularity in clinical use recently. Twenty Wistar rats weighing 200-250 g were used in our experiment. In 5 rats, the vascular anatomy of the groin and proximal thigh region was determined by anatomic dissection. The experimental design consisted of two groups. In the experimental group (N = 5), a flow-through epigastric skin flap was harvested based on the femoral artery, preparing both its proximal and distal stumps. The flap was transferred to the contralateral groin, and end-to-end vascular anastomosis was performed between a proximal and distal stump of the femoral arteries of the flap and recipient site. The proximal stump of the femoral vein of the flap was anastomosed to the femoral vein of the recipient site. The control group was divided into two subgroups. In all control group rats (N = 10), the flap was harvested in the same manner, and transferred to the contralateral groin, but standard free-flap procedure with one artery and one vein anastomosis was performed in 5 rats (conventional free-flap subgroup), and anastomosis was not performed between the flap and the recipient site in the remaining 5 rats (graft subgroup). Survival of the flap was evaluated on postoperative day 7 by direct observation, and microangiography was performed to delineate the vascularity of the flow-through flap. The results showed that all flaps survived in the experimental group and the conventional free-flap subgroup of the control group, whereas in the graft subgroup, all flaps underwent total necrosis. The authors conclude that the flow-through epigastric flap for the rat is a simple and reliable model for future physiologic and pharmacologic studies.     

Refinements in lower extremity free flap surgery

This chapter recommends numerous factors that are significant refinements in approach and execution of lower extremity free flaps. I encourage a clear conceptual separation between the two essential phases of successful reconstruction of problem wounds: wound preparation and flap transfer. I have found that antibiotic beads maintain the sterility of temporary bony dead space. Due emphasis should be given to preparation of the surgeon, patient, and wound, allowing a nonemergency approach to lower extremity free flap coverage. The surgeon needs to be familiar with a variety of flaps beyond the usual workhorse group. Also, attention should be paid to perioperative warmth and hydration, and vessels affected by posttraumatic vessel disease must be avoided. A positive attitude toward the use of vein grafts whenever necessary is important. I also favor careful planning of the exact size and shape of the flap and length of the vessels along with use of a widely spatulated technique of end-to-side anastomoses.     

A salvage composite free flap for improved prosthetics

A post-traumatic composite skin, muscle and bone defect in the left thigh with a 14-cm bone gap in the femur was secondarily reconstructed with a salvage osseomyocutaneous microvascular free tissue transfer of the tibia (18 cm), calf muscles and overlying skin (26×13 cm) harvested from the lower leg. The latter was amputated for chronic trophic ulceration of the foot and causalgia resulting from damage to the femoral and sciatic nerve in the primary injury. This situation resulted in an above-the-knee amputation stump with a better fitting and a more convenient prosthesis, rather than amputation at the hip joint.