Advances in microsurgery for upper and lower extremity reconstruction and limb preservation

Abstract

In the recent decades, microsurgical reconstruction has evolved from simple survival of the affected extremity to the improvement of functional and aesthetic outcome. This review retraces the main contributions to the advances of microsurgery for reconstruction of upper and lower extremities and limb preservation. In the upper extremity, it is important to restore fine motility, together with allowing prompt mobilization. In the lower limb, care must be taken in the reconstruction of weight-bearing areas and the aim must be proper ambulation and shoe wearing. Local perforator flaps can be considered for medium size defects. They provide thin coverage and can be performed in short operating time. Their use, though, is often limited by tissue availability. Free flaps allow to overcome this problem and, thanks to the recent development in the study of perforator vessels, the microsurgeon can choose the flap with the most appropriate characteristics. Chimeric flaps can accomplish simultaneous reconstruction of different tissue components and large bone defects often require vascularized bone reconstruction. When dealing with limb preservation it is very important to consider residual functionality. Functioning muscle transfer and targeted muscle re-innervation can be performed in these cases. A useful reconstructive tool in severely damaged limbs with limited blood supply is the use of cross-leg free flaps. In conclusion, extremity reconstruction and limb preservation are reaching new heights thanks, not only to the work of plastic surgeons, but also to the new developments in other fields of study such as oncology, traumatology, radiology and medical engineering.

One or two venous pedicles by anastomoses for free flaps in reconstruction of the lower extremity: A systematic review and meta‐analysis

“…Post‐traumatic inflammatory changes associated with the zone of injury, the incidence of peripheral vascular disease, and the unique physiology in the lower limb, all contribute to higher rates of reconstructive failure (Stranix et al, 2016; 2018). The risk of venous congestion and thrombosis is also highest in this anatomical region (Bolleta et al, 2019). The predisposition for lower limb venous stasis is further exacerbated in patients requiring post‐operative immobilization, which reduces the efficacy of the natural venous pumps of the soleus and gastrocnemius (Stranix et al, 2018).…”

Management of Complex Upper Extremity Trauma with Associated Vascular Injury

“…In upper extremity wounds, it is preferable to do fascio-cutaneous flap cover as it is easier for later re-elevation in cases where secondary surgeries are required. 53 54 ALT has the advantage of providing large skin cover with long good-sized vascular pedicle. It is a very versatile flap and can be used as a chimeric flap along with part of vastus lateralis, if needed.…”

“… 58 Muscle flaps have the disadvantage of difficulty in re-elevation for secondary surgeries. 53 54 Flap has to be elevated from the inset margin, and incisions in the middle of the flap are to be avoided.…”

The mangled extremity: assessment, decision making and outcomes

“…Advances in microsurgery techniques means that soft tissue reconstruction is becoming more attractive and widely available (33)(34)(35), however it is important to remember than not all cases are clear cut. Given the complexity of the decision to amputation or attempt limb salvage, scoring systems should be used only as a guide; instead more emphasis should be placed on the experience of the multidisciplinary team, and if possible, allowing the patient to make an informed decision (36).…”