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.
Even though there are many options for mandibular reconstruction, a free fibula osteocutaneous flap is regarded as the most frequently used flap. Despite having some previous anatomical studies pertaining to syndesmotic ligaments, there is no study pointing out that surgical landmarks can be used while free fibula osteocutaneous flaps are performed and used for surgical landmarks in order to avoid syndesmotic ligament injuries. Therefore, this study investigates the characteristics and relationship between inferior syndesmotic ligaments and fibula in cadavers. A total of 140 legs were obtained from 83 embalmed cadavers as well as other soft ones, which were donated for the inferior tibiofibular syndesmotic system's study. Detailed dissection and measurement of each ligament's distance to the end of the fibula and lateral malleolus were performed. Distances from the distal end of the fibula to anterior inferior tibiofibular ligament, posterior inferior tibiofibular, and inferior transverse ligament, and the lower border of the interosseous membrane are 3.5 AE 0.4 cm, 3.4 AE 0.5 cm, 1.9 AE 0.4 cm, and 5 AE 1 cm (mean AE SD), respectively. Distance from the most distal part of the fibula to lateral malleolus is 1.6 AE 0.4 cm (mean AE SD). Thus, the remaining distance of the fibular should be left at least 4 cm without disrupting the syndesmotic ligament complex. It is argued that the lateral malleolus can be applied as a surgical landmark while harvesting fibula.
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