Lower‐limb reconstruction with chimeric flaps: The quad flap^*

Abstract

Early soft-tissue coverage is critical for treating traumatic open lower-extremity wounds. As free-flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free-tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower-extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft-tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft-tissue loss. In case 1, a 51-year-old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53-year-old man sustained a right tibia plateau fracture with large soft-tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft-tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long-term complications in either case. Both patients achieved adequate soft-tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad-flap technique is promising for reconstructing the lower extremity.

Bilateral Lower Limb Salvage after Fourth-degree Burns: Subscapular Axis Free and Chimeric Flaps Effectiveness in Complex Reconstruction

“… 1 , 3 The flexibility of design and customized insetting with spatial independence of each component has revolutionized the ability to reconstruct extensive/complex defects and optimize limb salvage outcomes. 3 , 5 …”

“…Subscapular artery system flaps are versatile and reliable workhorses for lower extremity reconstruction, offering a variety of separate components (muscle, skin, fascia, and scapular bone) joining a common pedicle. 1 , 3 , 5 , 9 The chimeric LD/SA/scapular/parascapular combined flap is considered the largest coverage option for complex 3-dimensional lower extremity defects. 1 , 9 The LD large dimensions for tibia resurfacing, the SA slips for malleolus coverage, and parascapular gliding surface for tendinous coverage suited perfectly the defect features in our patient.…”

“… 1 – 3 Indications include significant soft-tissue or bone defects with vital structure exposure, resulting from trauma, burn injuries, irradiated wounds, osteomyelitis, or tumor excisions. 1 – 5 The ultimate goal of lower limb reconstruction is to achieve durable soft-tissue coverage over stable skeleton and preserve sensory and motor function. 4 Fourth-degree burns (full-thickness with deep tissue exposure) are severe traumatic injuries demanding either amputation or complex reconstruction.…”

Use of a sequential chimeric perforator flap for one‐stage reconstruction of complex soft tissue defects of the extremities

“…Bigdeli et al () reported that a conjoined parascapular and latissimus dorsi free flap is a large and reliable flap for simultaneous one‐stage reconstruction of complex and unusually large soft‐tissue defects in the knee region. Azouz et al (Azouz, Castel, Vijayasekaran, Rebecca, & Lettieri, ) described a quad flap, which consisted of contralateral composite parascapular and scapular fasciocutaneous flap and a serratus and latissimus dorsi muscle flap, for single‐stage large soft‐tissue coverage of extensive lower‐extremity injuries. However, those procedures often resulted in high donor site morbidity, a bulky appearance and an unstable mobile surface.…”

Variants of Extended Latissimus Dorsi Musculocutaneous Flap for Large Wounds in Extremities

“…Large skin and soft-tissue defects in extremities are still challenges faced by plastic and reconstructive surgeons. With the development of reconstructive methods improved, chimeric, sequential, and combined perforator ap transplantation are ideal ways to repair large defects with its low donor site morbidities [1][2][3] . But surgical complexity, operation time, and tolerance of surgical procedures still need to be improved.…”