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Nutthawut Akaranuchat, M.D.
Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, ailand.
Lower Extremity Reconstruction with Vascularized
Free-Tissue Transfer: 20 Years of Experience in
the Faculty of Medicine Siriraj Hospital, Mahidol
University, Bangkok, Thailand
ABSTRACT
Objective: e reconstruction of extensive so-tissue defects in the lower extremity still poses a great challenge
to plastic and reconstructive surgeons. e ideal approach is to achieve a proper so-tissue coverage with a well-
vascularized ap, which results in a durable weight-bearing surface and permits normal joint motion. is study
aims to retrospectively analyze the outcomes of lower-extremity reconstruction with vascularized free-tissue transfer
performed at our plastic surgery division.
Materials and Methods: A retrospective chart review was performed regarding 58 patients with defects in the lower
extremity which were reconstructed with vascularized free-tissue transfers between 2000 and 2019. Forty-four of
the patients were male, and 14 were female. e mean age was 44.4 years (range: 6-89 years). e most common
indication for free-ap surgery was a secondary reconstruction aer tumor eradication (23 cases, 39.7%), and 84.8%
of the defects were exposed bare bones, tendons, or joints.
Results: In our 58 reviewed cases, the foot was the most common area requiring reconstruction with a free ap
(68.9%), and the mean defect size was 12.5 x 8.1 cm. e most commonly used free ap was the Anterolateral thigh
free ap (39.7%), followed by the Gracilis free ap (29.3%), and the Supercial circumex iliac artery-perforator
free ap (10.4%). e recipient vessels most frequently used were posterior tibialis vessels (53.4%). e overall
ap-survival rate was 75.9%, though there was an increased survival rate of up to 85.7% in the last ve years of the
period studied. e ap-salvage rate was 40.9%, and arterial thrombosis was the major cause of ap loss (50%).
Factors associated with free-ap failure were re-exploration and free ap surgery aer tumor or cancer eradication.
e most common post-operative complication was ap-wound dehiscence (10.3%). Two patients received a ap
correction due to bulkiness, and three had recurrence of ulceration.
Conclusion: Microvascular free-tissue transfers for lower- extremity-defect reconstructions are reliable and valuable
as a surgical technique. In 20 years of experience, we’ve had an overall ap survival rate of 75.9%. Factors associated
with free-ap failure were re-exploration and free ap surgery aer tumor or cancer eradication. And our ap of
choice was the Anterolateral thigh free ap.
Keywords: Lower extremity reconstruction; foot reconstruction; free ap; microsurgery; ap surgery (Siriraj Med
J 2021; 73: 462-470)
Corresponding author: Nutthawut Akaranuchat
E-mail: nutthawut.aka@mahidol.ac.th, nutthawut.joe@gmail.com
Received 23 November 2020 Revised 17 March 2021 Accepted 19 March 2021
ORCID ID: https://orcid.org/0000-0003-1798-8484
http://dx.doi.org/10.33192/Smj.2021.60
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INTRODUCTION
Microvascular free-tissue transfers have become the
preferred reconstructive technique to manage complex
wounds and surgical defects aer an ablative procedure,
as the result of trauma. It is also the preferred technique
to deal with special-requirements situations such as
facial reanimation with a functioning muscle transfer in
facial-palsy patients. ere have been numerous clinical
reports on free-tissue transfer since the microvascular
technique was introduced in the early 1960s.
1-5
Previous data
demonstrate that microvascular free-tissue transfers allow
for reliable, single-stage, and immediate reconstruction
involving more complex defects from various etiologies.
6-17
Many case series have also reported a high ap-success
rate.
To date, reconstruction of extensive so-tissue
defects in the lower extremity still poses a great challenge
to reconstructive surgeons. A defect on the lower limb
will require some form of reconstruction in the majority
of cases. Also, permanent scar formation aer tight
closure or aer skin graing or inadequate local ap
use can result in pain and unstable wounds when a
person is bearing weight. us, the ideal approach to
treating a lower-limb defect is to achieve proper so-
tissue coverage with a well-vascularized ap, which
results in a durable weight-bearing surface and permits
normal ankle motion.
18
ere is no debate that only free
aps can cover extensive so tissue defects and provide
satisfactory functional outcomes without amputation.
19,20
At our institute, we started performing free-ap
reconstruction for defects in the lower extremities in1992,
but we had not collected the data nor had we evaluated
the nal outcomes aer surgery. is study aims to
retrospectively analyze the outcomes of lower-extremity
reconstruction with vascularized free-tissue transfer
performed at the Division of Plastic Surgery, Department
of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol
University.
MATERIALS AND METHODS
A retrospective chart review was conducted regarding
all patients who underwent free-ap surgery for lower-
extremity defect reconstruction at the Division of Plastic
Surgery, Department of Surgery, Faculty of Medicine Siriraj
Hospital from January, 2000 to December, 2019. e age,
gender, underlying disease, other risk factors (smoking,
obesity, etc.), American Society of Anesthesiologists
(ASA) classication, indication for surgery, location of
defect, type of ap, operative time, inow and outow
vessels, type of anastomosis, vein-gra usage, ischemic
time, length of hospital stay, length of intensive-unit
stay, ap-success rate, re-exploration surgery, salvage
rate, and perioperative complications of all the patients
were recorded. ese data were collected in a database
and were available for statistical analysis.
Data assessment
e total operative time was dened as the time
between the rst incision and the wound closure. e
ischemic time was dened as the time from the transection
of the vascular pedicle to a complete arterial anastomosis
and then the release of the vascular clamp. e ap-success
rate was dened as complete ap viability or partial ap
loss that still achieved the primary indication of surgery.
18
Complications were divided between ap- related and
general complications.
Statistical analysis of the data was performed using
the Statistical Package for the Social Sciences (SPSS). e
chi-square and Fisher’s exact test were used to statistically
compare variables that inuence the ap-success rate
and perioperative complications. A p-value of 0.05 or
less was regarded as statistically signicant.
RESULTS
Between January 2000 and December 2019, 58
microvascular free-tissue transfers for lower-extremity
reconstruction were performed to cover and/or reconstruct
various kinds of defects and diseases. ere were 44
men and 14 women ranging in age from 6 to 89 years
(mean: 44.4 years). Most of the cases involved a body
mass index (BMI) from 18.5-22.9 kg/m
2
(32.7%). Ten of
the 58 patients had underlying type 2 diabetic mellitus.
e three most common areas in the lower extremity
that needed reconstruction with a free ap were 1: a
foot (40 of 58, 68.9%), 2: a leg (14 of 58, 24.1%) and 3:
an ankle (5 of 58, 8.6%). Also, the plantar hind foot was
the most common area of the foot that needed coverage
(18 0f 58, 31.1%). Among the 58 patients, there were
23 defects (39.7%) caused from tumor eradication, 19
defects (32.8%) due to trauma, and 8 defects (13.8%)
resulting from post-operative debridement due to severe
so-tissue infection. Fiy-ve of the 58 cases (84.8%)
were defects that exposed bare bones, bare tendons, or
joints.
Seventy percent of the defects were between 5-15 cm.
(41 of 58, 70.7%); the mean defect size was 12.5 x 8.1 cm.
(a range from 3-26 cm.). e three most common ap
types for reconstructing a lower-extremity defect were
the Anterolateral thigh (ALT) free ap (23 of 58, 39.7%),
followed by Gracilis free ap (17 of 58, 29.3%), and the
Supercial circumex iliac artery perforator (SCIP) free
ap (6 of 58, 10.4%). e recipient arteries frequently
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464
used for anastomosis were the posterior tibialis artery
(31 of 58, 53.4%), the anterior tibialis artery (11 of 58,
19%), and the dorsalis pedis artery (8 of 58, 13.8%). More
than 70% (45 of 58) of the cases were performed with
one artery and one vein anastomosis, and 75.9% (44 of
58) of the patients had an arterial anastomosis with the
end-to-end anastomotic technique (end to side, 24.1%).
Most of the cases resulted, primarily, in a closing of the
donor-site defect (42 of 58, 72.4%). (Table 1)
The mean duration of the total operative time
(including surgical resection) was 520 minutes (range:
330-960 minutes). e mean ap harvesting time was
76 minutes (range: 40-120 minutes). e mean ischemic
time was 59 minutes (range: 36-115 minutes). (Fig 1)
For post-operative outcomes, the overall ap-survival
rate was 75.9% (44 of 58 patients). Re-exploration for
anastomosis revisions was performed in 22 of 58 cases
(37.9%), with a aps-salvaging success rate of 40.9% (9 of 22
cases). e most common cause of ap revision was venous
congestion (11 of 22 cases, 50%), but the most common
cause of total ap failure was arterial thrombosis (7 of 14
cases, 50%). e recipient-site complications included
wound dehiscence (6 of 58 cases, 10.3%), surgical-site
infection (4 of 58 cases, 6.9%), and skin-gra loss (4 of
58 cases, 6.9%). Donor-site complications were found
in 8.6% of patients, and the most common complication
was wound dehiscence (2 of 58 cases, 3.5%). (Table 2)
Due to advances in microsurgical techniques and
the better quality of microscopes and other instruments,
the outcomes of lower-extremity reconstruction were
signicantly better than previous outcomes. In our
institute, the overall free-ap survival rate rose from 66.7%
(2000-2014) to 85.7% (2015-2019). Some microsurgeons
have performed a more sophisticated ap to serve the
specic requirements of the patient with the aim of
restoring both the function and the appearance. (Table 4)
DISCUSSION
A major development in the reconstruction of
defects in various locations was the introduction of
free vascularized tissue transfer in the 1960s and 1970s,
which enabled primary reconstruction of more complex
and extensive defects. Our retrospective study presents
our sta’s experience in performing 58 microvascular
free-tissue transfers for lower- extremity reconstruction
over the last ten years, and it revealed a success rate
of 75.9%. e majority of defects were connected to
tumor ablative surgery and were between 5-15 cm. in the
largest dimension. A gracilis muscle free ap with skin
graing was frequently done in the past, but the ALT
free ap is our free ap of choice for lower-extremity
reconstruction, due to its harvesting in a very large ap
size, its long pedicle length, its low donor-site morbidity,
and its modications, such as enabling the inclusion of
fascia or muscle into the ap.
21
e re-exploration rate
in our series was 37.9%, with a salvage rate of 40.9%,
which is quite low when compared to results from other
studies.
22-24
In the last ve years, the ap-salvage rate has
signicantly improved, from 16.7% (2000-2014) to 70%
(2015-2019). (Tables 3 and 4)
Factors that inuence ap failure and associated
complications continue to be debated. Reported factors
related to ap failure are the pre-operative status of the
patient, his or her age, smoking, pre-operative radiation, ap
type, surgical expertise, use of a vein gra, operative time,
and re-exploration for anastomosis revision; however, we
still do not have sucient prospective data to denitively
identify all of the signicant causes. e factors related
to wound complications and general complications were
age, ASA class, diabetes mellitus, pre-operative radiation,
smoking, and alcohol consumption, but there remains
a lack of prospective data to denitively identify all of
the signicant causes.
7,14,25-29
For our report, re-explorative surgery and free ap
surgery aer tumor or cancer eradication were signicant
factors vis a vis total ap failure. e failure rate of free-
ap surgery signicantly decreased commensurate with
the increase in surgical expertise. (Tables 3 and 4)
CONCLUSION
Microvascular free-tissue transfers are reliable and
valuable as a surgical technique in achieving successful
lower- extremity defect reconstructions. At our institute,
we began performing free-ap reconstruction for defects
in the lower extremities in 1992. For the past 20 years,
the overall ap-survival rate was 75.9% (44 of 58 cases);
the re-exploration rate was 37.9% (22 of 58 cases); and
the rate of successfully salvaging aps was 40.9% (9 of
22 cases). e anterolateral thigh free ap was the ap of
choice in our lower-extremity defect reconstruction. e
most commonly used recipient vessels were the posterior
tibialis artery and vein. In our institute’s experience,
the key factors associated with lower extremity free-
ap failure were re-exploration and free ap surgery
aer tumor or cancer eradication. Finally, this study
presents 20 years of experience and surgical outcomes in
lower-extremity defect reconstruction with vascularized
free-tissue transfers at the Division of Plastic Surgery,
Department of Surgery, Faculty of Medicine Siriraj
Hospital, Mahidol University. ese results present a
current baseline for lower-extremity free-ap surgery
to which future advances in technique and practice may
be compared.
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TABLE 1. Patients’ demographic and clinical data.
Characteristics
Number of patients 58
Mean age, year (range) 44.4 (6-89)
Sex, male (%): female (%) 44 (75.9%): 14 (24.1%)
Body mass index, BMI (%)
<18.5 11 / 58 (19.0%)
18.5 - 22.9 19 / 58 (32.7%)
23.0 - 24.9 12 / 58 (20.7%)
25.0 - 29.9 15 / 58 (25.9%)
30 - 40 1 / 58 (1.7%)
40.1 - 50 no
>50 no
ASA classication
Class I 38
Class II 9
Class III 10
Class IV 1
Underlying disease
Diabetic mellitus no. (%) 10 / 58 (17.2%)
Smoking no. (%) 7 / 58 (12.1%)
Peripheral arterial disease no. (%) 5 / 58 (8.6%)
Hypertension no. (%) 8 / 58 (13.8%)
Dyslipidemia no. (%) 3 / 58 (5.2%)
Paraparesis or paraplegia 2 / 58 (3.4%)
Hemiparesis or hemiplegia 1 / 58 (1.7%)
Tumor or cancer 2 / 58 (3.4%)
Chronic renal failure 1 / 58 (1.7%)
Defect site no. (%)
Thigh 1 / 58 (1.7%)
Knee 3 / 58 (5.2%)
Popliteal fossa no
Leg 14/58 (24.1%)
Proximal third leg no
Middle third leg 1 / 58 (1.7%)
Distal third leg 2 / 58 (3.4%)
Proximal and middle third leg no
Middle and distal third leg 3 / 58 (5.2%)
Proximal, Middle and distal third leg 3 / 58 (5.2%)
Ankle 5 / 58 (8.6%)
Foot 40/58 (68.9%)
Dorsal of foot 7 / 58 (12.1%)
Plantar forefoot 4 / 58 (6.9%)
Plantar midfoot 2 / 58 (3.4%)
Plantar hindfoot 18 / 58 (31.1%)
Plantar forefoot and midfoot 3 / 58 (5.2%)
Plantar midfoot and hindfoot 5 / 58 (8.6%)
Plantar forefoot, midfoot and hindfoot 1 / 58 (1.7%)
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Defect size no. (%)
Small defect (<5 cm) 3 / 58 (5.2%)
Medium defect (5-10 cm) 22 / 58 (37.9%)
Large defect (10.1-15 cm) 19 / 58 (32.8%)
Very large defect (15.1-20 cm) 8 / 58 (13.8%)
Giant defect (>20 cm) 6 / 58 (10.3%)
Etiology no. (%)
Trauma 19 / 58 (32.8%)
Tumor or cancer eradication 23 / 58 (39.7%)
Infection 8 / 58 (13.8%)
Ischemic ulcer 2 / 58 (3.4%)
Venous ulcer no
Diabetic ulcer or neuropathic ulcer 4 / 58 (6.9%)
Irradiation no
Unstable scarring 2 / 58 (3.4%)
Exposure to bone, tendon, or joint no. (%) 55 / 58 (84.8%)
Mean defect size (Length x width, cm) 12.5 x 8.1 cm (Range 3-26 cm)
Flap source artery no. (%)
Branch of lateral circumex femoral artery 3 / 58 (5.2%)
Popliteal artery no
Posterior tibialis artery 31 / 58 (53.4%)
Medial plantar artery 3 / 58 (5.2%)
Anterior tibialis artery 11 / 58 (19.0%)
Dorsalis pedis artery 8 / 58 (13.8%)
Peroneal artery 1 / 58 (1.7%)
Lateral supramalleolar artery 1 / 58 (1.7%)
Number of anastomosis no. (%)
1 artery:1 vein 45 / 58 (77.6%)
1 artery:2 vein 13 / 58 (22.4%)
Type of arterial anastomosis no. (%)
End to end 44 / 58 (75.9%)
End to side 14 / 58 (24.1%)
Free ap no (%)
ALT free ap 23 / 58 (39.7)
VL free ap 1 / 58 (1.7%)
Latissimus dorsi free ap 3 / 58 (5.2%)
Gracilis free ap 17 / 58 (29.3)
MSAP free ap 4 / 58 (6.9%)
SCIP free ap 6 / 58 (10.4%)
Radial forearm free ap 1 / 58 (1.7%)
Parascapular free ap 1 / 58 (1.7%)
Internal oblique muscle free ap 1 / 58 (1.7%)
Temporoparietal fascial free ap 1 / 58 (1.7%)
Flap composition no. (%)
Fasciocutaneous ap 34 / 58 (58.6%)
Muscle ap 18 / 58 (31.1%)
Musculocutaneous ap 4 / 58 (6.9%)
Fascial ap 1 / 58 (1.7%)
Osteocutaneous ap 1 / 58 (1.7%)
Donor-site closure no (%)
Primary closure 42 / 58 (72.4%)
STSG 16 / 58 (27.6%)
Abbreviations: ASA = American Society of Anesthesiologists; ALT = Anterolateral thigh; VL = Vastus lateralis; MSAP = Medial sural artery
perforator; SCIP = Supercial circumex iliac artery perforator; STSG = Split-thickness skin gra
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Fig 1. Le plantar midfoot defect aer tumor eradication.
e defect was reconstructed with supercial circumex
iliac artery perforator free ap which harvested from le
groin area. Donor site defect was closed primarily. Inset
ap was done and the microvascular anastomosis was
performed with lateral plantar vessels.
TABLE 2. Post-operative surgical outcomes.
Flap survival no. (%) 44 / 58 (75.9%)
Flap loss no. (%)
Partial loss no. (%) 11 / 58 (19.0%)
Complete loss no. (%) 14 / 58 (24.1%)
Arterial thrombosis no. (%) 7 / 14 (50.0%)
Venous thrombosis no. (%) 6 / 14 (42.9%)
Hypercoagulable stage no. (%) 1 / 14 (7.1%)
Flap revision no. (%) 22 / 58 (37.9%)
Arterial insufciency no. (%) 10 / 22 (45.5%)
Venous congestion no. (%) 11 / 22 (50%)
Bleeding hematoma 1 / 22 (4.5%)
Flap salvage no. (%) 9 / 22 (40.9%)
Recipient site complication no. (%) 19 / 58 (32.8%)
Infection no. (%) 4 / 58 (6.9%)
Dehiscend wound no. (%) 6 / 58 (10.3%)
STSG loss no. (%) 4 / 58 (6.9%)
Hematoma no. (%) 2 / 58 (3.5%)
Seroma no. (%) no
Donor site complication no. (%) 5 / 58 (8.6%)
Infection no. (%) 1 / 58 (1.7%)
Dehiscend wound no. (%) 2 / 58 (3.5%)
STSG loss no. (%) 1 / 58 (1.7%)
Hematoma no. (%) no
Seroma no. (%) 1 / 58 (1.7%)
Flap correction
Debulging no. (%) 2 / 44 (4.5%)
Recurrent ulcer no. (%) 3 / 44 (6.8%)
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TABLE 3. Data comparisons between the group of ap success and ap failure.
Comparative data Flap success (%) Flap failure (%) p-value
Case 44 (75.9%) 14 (24.1%) 0.165
Year 2000-2014 20 (66.7%) 10 (33.3%)
Year 2015-2019 24 (85.7%) 4 (14.3%)
Sex 0.931
Male 33 (75%) 11(25%)
Female 11(78.6%) 3 (21.4%)
ASA classication 0.913
Class I 29 (76.3%) 9 (23.7%)
Class II 7 (77.8%) 2 (22.2%)
Class III 7 (70%) 3 (30%)
Class IV 1 (100%) 0 (0%)
Cause
Trauma 17 (89.5%) 2 (10.5%) 0.173
Tumor or cancer eradication 13 (56.5%) 10 (43.5%) 0.013*
Infection 7 (87.5%) 1 (12.5%) 0.701
Ischemic ulcer 2 (100%) 0 (0%) 0.977
Diabetic ulcer or Neuropathic ulcer 3 (75%) 1 (25%) 0.573
Unstable scarring 2 (100%) 0 (0%) 0.977
Underlying disease
Diabetic mellitus no. (%) 7 (70%) 3 (30%) 0.944
Smoking no. (%) 6 (85.7%) 1 (14.3%) 0.858
Peripheral arterial disease no. (%) 4 (80%) 1 (20%) 0.749
Hypertension no. (%) 8 (100&) 0 (0%) 0.203
Dyslipidemia no. (%) 3 (100%) 0 (0%) 0.756
Paraparesis or paraplegia 2 (100%) 0 (0%) 0.977
Hemiparesis or hemiplegia 1 (100%) 0 (0%) 0.542
Tumor or cancer 1 (50%) 1 (50%) 0.977
Chronic renal failure 1 (100%) 0 (0%) 0.542
Flap revision <0.001*
Yes (22 / 58, 37.9%) 9 / 21 (40.9%) 12 / 21 (59.1%)
No (36 / 58, 62.1%) 35 / 37 (94.4%) 2 / 37 (5.6%)
Abbreviation: ASA = American Society of Anesthesiologists
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What is already known on this topic?
Based on the previous studies, the overall failure rate
of microvascular free-ap reconstruction was 5 to 10%.
Factors involved in free-ap failure and complications are
still debated. Reported factors that relate to ap-failure
include the patients’ pre-operative status, age, smoking,
pre-operative radiation, ap type, surgical expertise,
use of vein gra, operative time, and re-exploration for
anastomosis revision, but we still did not have sucient
prospective data to denitively identify all the signicant
causes.
What this study adds
Our institution has operated the microvascular free
ap for lower-extremity reconstruction since 1992, but
we had not previously collected data or had any long-
term outcomes. is retrospective review presents our
20 years of clinical experience with 58 microvascular
free-ap reconstruction from various kinds of indication.
Our study is not only the rst-ever data report from our
institute, but may also be the rst and largest report of
lower-extremity free-ap reconstruction in ailand.
Potential conicts of interest
e author declares that there are no conicts of
interest related to this study.
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TABLE 4. Data comparisons between the group that had surgery from 2000-2014 versus 2015-2019.
Comparative data Year 2000-2014 Year 2015-2019 p-value
Total cases 30 cases 28 cases 0.165
Flap success no (%) 20 / 30 (66.7%) 24 / 28 (85.7%)
Flap failure no (%) 10 / 30 (33.3%) 4 /28 (14.3%)
Flap revision no (%) 12 / 30 (40%) 10 / 28 (35.71%) 0.948
Arterial insufciency no. (%) 6 / 12 (50%) 4 / 10 (40%)
Venous congestion no. (%) 6 / 12 (50%) 5 / 10 (50%)
Bleeding hematoma 0 / 12 (0%) 1 / 10 (10%)
Flap salvage no (%) 2 / 12 (16.7%) 7 / 10 (70%) 0.036*
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Akaranuchat.
