Algorithm for Free Perforator Flap Selection in Lower Extremity Reconstruction Based on 563 Cases

Abstract

Background: Microsurgical lower extremity reconstruction remains a challenge. The use of perforator flaps in lower extremity reconstruction is expanding. The authors present an algorithm to guide in the selection of the ideal free perforator flap that can be tailored to each lower extremity defect. Methods: The authors conducted a retrospective review of lower extremity reconstruction using free perforator flaps over a 7-year period. Demographics, comorbidities, defect characteristics, operative details, complications, and secondary procedures were documented. Pairwise comparisons of flap types were performed to differentiate flaps on the basis of flap size, thickness, and pedicle length. Results: A total of 563 free perforator flaps were performed. The most common causes were trauma (36.5 percent) and diabetes (24.4 percent). Nine flaps were used, with the most common being superficial circumflex iliac perforator (51.2 percent) and anterolateral thigh (33.2 percent). Size differed significantly between flap types (p < 0.05), with the exception of thoracodorsal artery perforator versus gluteal artery perforator flaps (p = 0.26). The thinnest flaps were posterior interosseous artery perforator (3.7 ± 0.5 mm) and superficial circumflex iliac perforator (5.4 ± 0.8 mm). The thickest flaps were deep inferior epigastric perforator (11.1 ± 3.9 mm) and anterolateral thigh (9.0 ± 1.5 mm). The shortest pedicles were in posterior interosseous artery perforator (3.3 ± 0.3 cm) and superficial circumflex iliac perforator flaps (5.2 ± 0.8 cm). The longest pedicles were in deep inferior epigastric perforator (11.7 ± 1.4 cm), thoracodorsal artery perforator (9.3 ± 1.4 cm), and anterolateral thigh flaps (9.2 ± 0.8 cm). Conclusions: Free perforator flaps are reliable in lower extremity reconstruction. The authors believe their algorithm for flap selection helps to optimize form and function, decrease operative time, and minimize donor-site morbidity and secondary procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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

“…Over the past two decades the indications for perforator flaps reconstruction have increased due to the better understanding of the anatomy and distribution of perforator vessels [5,26] . These flaps can be used as local flaps and transposed to the defect through a wide range of movements (i.e., V-Y advancement, rotation, etc.)…”

“…It can be utilized with a portion of the fascia lata to reconstruct tendons as well (i.e., the Achilles) [76] . Abdelfattah et al [5] evaluated free perforator flaps, other than ALT, for the reconstruction of lower limb defects, including superficial circumflex iliac perforator (SCIP), gluteal artery perforator (GAP), thoracodorsal artery perforator (TDAP), deep inferior epigastric perforator (DIEP), posterior interosseous artery perforator (PIAP), upper medial thigh perforator, and medial sural artery perforator (MSAP) flaps in their 563 cases experience. They propose an algorithm for flap selection based on the characteristics of each flap [5] .…”

“…Abdelfattah et al [5] evaluated free perforator flaps, other than ALT, for the reconstruction of lower limb defects, including superficial circumflex iliac perforator (SCIP), gluteal artery perforator (GAP), thoracodorsal artery perforator (TDAP), deep inferior epigastric perforator (DIEP), posterior interosseous artery perforator (PIAP), upper medial thigh perforator, and medial sural artery perforator (MSAP) flaps in their 563 cases experience. They propose an algorithm for flap selection based on the characteristics of each flap [5] . Other than the already described ALT, SCIP and DIEP flaps, GAP flaps appeared to be indicated in moderate size defects located in the posterior body surface but, as a drawback, they have a short pedicle and may require supermicrosurgical technique [77,78] .…”

“…In the lower extremity, reaching a functional reconstruction that allows the patient to walk properly without pain is the primary goal, even though, nowadays, reaching an aesthetic reconstruction is always desirable, when possible [2][3][4] . Today, many have come to agree that a microsurgical approach is the standard of care in most cases of extremity reconstruction and limb preservation [5] . Many different flaps can be used in order to reconstruct bone defects, muscular function and soft tissue coverage.…”

Photoacoustic microscopy: a novel approach for studying perforator skin flap in a mouse model

“…Thus, choke vessels make it feasible to harvest larger perforator flaps by incorporating neighboring perforasomes into the flap based on an individual perforator, such as multiterritory perforator flaps. Yet, the clinical use of multiterritory perforator flaps is often hindered by distal partial necrosis occurring at the adjacent choke vessel boundary, which is caused by poor understanding of the choke vessels that play an indispensable role in flap expansion and survival (10). To our knowledge, the current approaches to the morphological study of the choke vessels cannot realize the aim of providing noninvasive, dynamic, and in vivo observation.…”