Lower Extremity Reconstruction with Vascularized Free-Tissue Transfer: 20 Years of Experience in the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Nutthawut Akaranuchat

doi:10.33192/Smj.2021.60

Authors

Nutthawut Akaranuchat Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand

DOI:

https://doi.org/10.33192/Smj.2021.60

Keywords:

Lower extremity reconstruction, foot reconstruction, free flap, microsurgery, flap surgery

Abstract

Objective: The reconstruction of extensive soft-tissue defects in the lower extremity still poses a great challenge to plastic and reconstructive surgeons. The ideal approach is to achieve a proper soft-tissue coverage with a well-vascularized flap, which results in a durable weight-bearing surface and permits normal joint motion. This 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. The mean age was 44.4 years (range: 6-89 years). The most common indication for free-flap surgery was a secondary reconstruction after 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 flap (68.9%), and the mean defect size was 12.5 x 8.1 cm. The most commonly used free flap was the Anterolateral thigh free flap (39.7%), followed by the Gracilis free flap (29.3%), and the Superficial circumflex iliac artery-perforator free flap (10.4%). The recipient vessels most frequently used were posterior tibialis vessels (53.4%). The overall flap-survival rate was 75.9%, though there was an increased survival rate of up to 85.7% in the last five years of the period studied. The flap-salvage rate was 40.9%, and arterial thrombosis was the major cause of flap loss (50%). Factors associated with free-flap failure were re-exploration and free flap surgery after tumor or cancer eradication. The most common post-operative complication was flap-wound dehiscence (10.3%). Two patients received a flap 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 over 20 years of experience in our division, we’ve had an overall flap-survival rate of 75.9%. Our flap of choice was the Anterolateral thigh free flap.

References

1. Irons GB, Wood MB, Schmitt EH. Experience with one hundred consecutive free flaps. Annals of plastic surgery. 1987 Jan;18(1):17–23.
2. Harashina T. Analysis of 200 free flaps. British Journal of Plastic Surgery. 1988;41:33–6. 3. N. J. Percival, P. J. Sykes MJE. Free flap surgery: the Welsh Regional Unit experience. British Journal of Plastic Surgery. 1989;42:435–40.
4. Schusterman MA, Miller MJ, Reece GP, Kroll SS, Marchi M, Goepfert H. A Single Center’ s Experience with 308 Free Flaps for Repair of Head and Neck Cancer Defects. Plastic and reconstructive surgery. 1994;93:472–80.
5. Kruavit A, Visuthikosol V, Srimuninnimit V, Punyahotra N. 10-Year-Free Flaps at Ramathibodi Hospital. Journal of the International College of Surgeons of Thailand. 1998;41:45–59.
6. Kelly JL, Eadie P a, Orr D, Al-Rawi M, O’Donnell M, Lawlor D. Prospective evaluation of outcome measures in free-flap surgery. Journal of reconstructive microsurgery. 2004 Aug;20(6):435–8; discussion 439.
7. Classen D a, Ward H. Complications in a consecutive series of 250 free flap operations. Annals of plastic surgery. 2006 May ;56(5):557–61.
8. Shpitzer T, Neligan PC, Gullane PJ, Freeman JE, Boyd BJ, Rotstein LE, et al. Oromandibular Reconstruction With the Fibular Free Flap. Arch Otolaryngol Head Neck Surg. 1997;123:46–55.
9. Urken ML, Buchbinder D, Costantino PD, Sinha U, Okay D, Lawson W, et al. Oromandibular Reconstruction Using Microvascular Composite Flaps. Arch Otolaryngol Head Neck Surg. 1998;124:46–55.
10. Hamdi M, Weiler-Mithoff EM, Webster MH. Deep inferior epigastric perforator flap in breast reconstruction: experience with the first 50 flaps. Plastic and reconstructive surgery. 1999 Jan;103(1):86–95.
11. Cordeiro PG, Disa JJ, Hidalgo D a, Hu QY. Reconstruction of the mandible with osseous free flaps: a 10year experience with 150 consecutive patients. Plastic and reconstructive surgery. 1999 Oct;104(5):1314–20.
12. Nakatsuka T, Harii K, Asato H, Takushima A, Ebihara S, Kimata Y, et al. Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection. Journal of reconstructive microsurgery. 2003 Aug;19(6):363–8; discussion 369.
13. Suh JD, Sercarz J a, Abemayor E, Calcaterra TC, Rawnsley JD, Alam D, et al. Analysis of outcome and complications in 400 cases of microvascular head and neck reconstruction. Archives of otolaryngology head & neck surgery. 2004 Aug;130(8):962–6.
14. Eckardt a, Meyer a, Laas U, Hausamen J-E. Reconstruction of defects in the head and neck with free flaps: 20 years experience. The British journal of oral & maxillofacial surgery. 2007 Jan;45(1):11–5.
15. Pohlenz P, Blessmann M, Blake F, Li L, Schmelzle R, Heiland M. Outcome and complications of 540 microvascular free flaps: the Hamburg experience. Clinical oral investigations. 2007 Mar;11(1):89–92.
16. Wettstein R, Schürch R, Banic A, Erni D, Harder Y. Review of 197 consecutive free flap reconstructions in the lower extremity. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2008 Jul;61(7):772–6.
17. Acosta R, Smit JM, Audolfsson T, Darcy CM, Enajat M, Kildal M, et al. A clinical review of 9 years of free perforator flap breast reconstructions: an analysis of 675 flaps and the influence of new techniques on clinical practice. Journal of reconstructive microsurgery. 2011 Feb;27(2):91–8.
18. Hallock GG. A paradigm shift in flap selection protocols for zones of the lower extremity using perforator flaps. J Reconstr Microsurg. 2013; 29:233–240.
19. Hong JP, Shin HW, Kim JJ, Wei F-C, Chung YK. The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity. Plast Reconstr Surg 2005;115:142–147.
20. Rodriguez ED, Bluebond-Langner R, Copeland C, Grim TN, Singh NK, Scalea T. Functional outcomes of posttraumatic lower limb salvage: A pilot study of anterolateral thigh perforator flaps versus muscle flaps. J Trauma 2009;66:1311–1314.
21. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002; 109: 2219-26.
22. Chubb D, Rozen WM, Whitaker IS, Acosta R, Grinsell D, Ashton MW. The efficacy of clinical assessment in the postoperative monitoring of free flaps: a review of 1140 consecutive cases. Plast Reconstr Surg 2010; 125: 1157-66.
23. Rozen WM, Chubb D, Whitaker IS, Acosta R. The efficacy of postoperative monitoring: a single surgeon comparison of clinical monitoring and the implantable Doppler probe in 547 consecutive free flaps. Microsurgery 2010; 30: 105-10.
24. Chen KT, Mardini S, Chuang DC, Lin CH, Cheng MH, Lin YT, et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120: 187-95.
25. Khouri RK, Cooley BC, Kunselman AR, Landis JR, Yeramian P, Ingram D, et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg 1998; 102: 711-21.
26. Kruse AL, Luebbers HT, Gratz KW, Obwegeser JA. Factors influencing survival of free-flap in reconstruction for cancer of the head and neck: a literature review. Microsurgery 2010; 30: 242-8.
27. Pattani KM, Byrne P, Boahene K, Richmon J. What makes a good flap go bad? A critical analysis of the literature of intraoperative factors related to free flap failure. Laryngoscope 2010; 120: 717-23.
28. Bourget A, Chang JT, Wu DB, Chang CJ, Wei FC. Free flap reconstruction in the head and neck region following radiotherapy: a cohort study identifying negative outcome predictors. Plast Reconstr Surg 2011; 127: 1901-8.
29. Herold C, Gohritz A, Meyer-Marcotty M, Steiert A, Jokuszies A, Vaske B, et al. Is there an association between comorbidities and the outcome of microvascular free tissue transfer? J Reconstr Microsurg 2011; 27: 127-32.