Reconstruction of Lower Extremity Defects Using the Serratus Anterior Free Flap: A Systematic Review and Retrospective Case Series

Abstract

Background Free tissue transfer is the most common modality for distal third lower extremity reconstruction, yet complication rates remain high. The serratus anterior muscle free flap, which can be harvested alone or as a chimeric flap, is a robust and reliable option that remains the primary modality for distal third lower extremity defects at our institution. The objective of this study was to perform a systematic review of lower extremity reconstruction with the serratus anterior free flap and provide a retrospective review of cases at our institution. Methods A systematic review of the literature was conducted using PubMed, Embase, and Cochrane Library (PROSPERO CRD42018110692). Articles reporting reconstruction of lower extremity and foot defects using serratus anterior free flaps in adults were included. A retrospective cohort study of serratus anterior free flaps was then performed from 2012 to 2018 at our institution. Results Thirty-seven articles meeting inclusion criteria provided data on 198 flaps: 125 (63%) serratus-only flaps and 73 (37%) chimeric flaps based on the subscapular axis. Among the serratus-only flaps, defects were primarily due to chronic wounds (51%) or acute infections (33%). Flap survival rate was 97%, and the major and minor complication rates were 5 and 9%, respectively. Of the 10 cases included in the case series, flap survival rate was 100%, there were no major complications, and the minor complication rate was 44%. The average time to flap healing was 95 days and average lower extremity functional scale score was 58/80 among five patients. Conclusion Serratus anterior muscle free flaps are a versatile and reliable option for distal third lower extremity reconstruction.

Combined Tissue Transfer for Extensive Lower Limb Complex Defects: Flow-through Flaps, Chimera, and “Orochi” Flaps

“…In 2011, Hallock et al announced a new classification in which Koshima's chimera is a subtype of Hallock's chimera flap, 9 but many articles still report the original Hallock's chimera as a chimeric flap. 20,21 Therefore, since 2017, Koshima continues to report the Koshima's chimera flap, including the multistage combined flap, as the "Orochi" flap, by further developing the conventional one-stage Koshima's chimera (American Society of Reconstructive Microsurgery, Breakout Panel, Waikoloa, Hawaii, January 17, 2017, etc., 12 webinar 2020 17,18 ).…”

Nutritional markers for predicting lower extremity free tissue transfer outcomes in the chronic wound population

“…The chronic wound population is a highly comorbid population, with high rates of diabetes, peripheral vascular disease, osteomyelitis, and tobacco use (Black et al, 2020). Despite this, free tissue transfer (FTT) remains an excellent option for the treatment of defects secondary to LE chronic wounds (Black et al, 2020; Karir et al, 2020; Kolbenschlag et al, 2013). Free flaps used in the LE have proven to be a reliable reconstructive modality with flap survival rates as high as 97% and high rates of postoperative ambulation (Karir et al, 2020; Lu et al, 2019).…”

“…Despite this, free tissue transfer (FTT) remains an excellent option for the treatment of defects secondary to LE chronic wounds (Black et al, 2020; Karir et al, 2020; Kolbenschlag et al, 2013). Free flaps used in the LE have proven to be a reliable reconstructive modality with flap survival rates as high as 97% and high rates of postoperative ambulation (Karir et al, 2020; Lu et al, 2019). Based on the Lower Extremity Function Scale (LEFS), a validated scoring system to assess lower limb functional activity, limb salvage patients successfully treated with FTT reconstruction maintain superior physical functionality compared to lower limb amputation patients and demonstrate an adequate ability for independent community living (Falola et al, 2018).…”

Outcomes of Free Muscle Flaps versus Free Fasciocutaneous Flaps for Lower Limb Reconstruction following Trauma: A Systematic Review and Meta-Analysis

“…The ability to transfer well-vascularized, healthy tissue to a traumatized lower extremity have solidified orthoplastic approaches to these injuries and the use of microvascular free flaps to salvage the limb and avoid amputations. [1][2][3][4][5] Historically, muscle free flaps have been utilized for lower limb salvage after trauma 6 as it has been hypothesized that their increased vascularity promotes faster healing, bony union, collagen deposition, and prevention of infections [7][8][9] while also enabling coverage of large wounds with better aesthetic outcomes. 10,11 While muscle free flaps were the mainstay of treatment, fasciocutaneous free flaps were developed for a variety of reasons.…”