Repair of a wide lower extremity defect with cross-leg free transfer of latissimus dorsi and serratus anterior combined flap: a case report

Abstract

Composite tissue loss in extremities involving neurovascular structures has been a major challenge for reconstructive surgeons. Reconstruction of large defects can only be achieved with microsurgical procedures. The success of free flap operations depends on the presence of healthy recipient vessels. In cases with no suitable donor artery and vein or in which even the use of vein grafts would not be feasible, the lower limb can be salvaged with a cross-leg free flap procedure. We present a case with a large composite tissue loss that was reconstructed with cross-leg free transfer of a combined latissimus dorsi and serratus anterior muscle flap. This case indicates that this large muscle flap can survive with the cross-leg free flap method and this technique may be a viable alternative for large lower extremity defects that have no reliable recipient artery.

The cross‐leg free flap: A systematic review of the literature

“…In addition to soft tissue reconstruction, and in keeping with the first description of CLFF, authors such as Yu et al and Ciudad et al reported the inclusion of osseous components. This did not appear to substantially prolong time to pedicle division, which overall varied from a few days to 6 weeks across reports (Zhang et al, 2012a; Bali et al, 2020; Bishop et al, 2018; Ciudad et al, 2020; Zhang et al, 2012b; Hamdi et al, 2000; Lu et al, 2013; Serel et al, 2006; Topalan & Ermis, 2001; Turgut et al, 2010; Woo et al, 2006) (Figure 3d). Ischemic preconditioning by way of intermittent pedicle occlusion was widely adopted prior to pedicle division (Bishop et al, 2018; Ciudad et al, 2020; Topalan & Ermis, 2001).…”

“…All patient in the studies reported by Townsend, Sengezer et al, and Manrique et al experienced adverse events (Manrique et al, 2018; Sengezer et al, 1997; Townsend, 1987). In contrast, Bishop et al, Serel et al, Turgut et al, Topalan and Ermis, Hamdi et al, Yu et al, Zhang et al, 2012a; Lai et al, Karisdag et al, Hodgkinson et al, Lu et al, and Ciudad et al reported no adverse events (0%) (Bishop et al, 2018; Ciudad et al, 2020; Zhang et al, 2012b; Hamdi et al, 2000; Hodgkinson et al, 1994; Karşıdağ et al, 2011; Lai et al, 1991; Lu et al, 2013; Serel et al, 2006; Topalan & Ermis, 2001; Turgut et al, 2010; Yu et al, 2012). The adverse events included n = 6 instances of partial skin graft loss, n = 5 cases with prolonged pain, n = 4 instances of hematoma, n = 2 instances of venous thrombosis salvaged with vein grafts, n = 1 partial graft loss, n = 1 reports of free flap failure requiring amputation, n = 1 instance of secondary cancellous bone graft due to nonunion, and n = 1 instance of seroma.…”

“…Our systematic review of the literature shows that CLFFs have been used to treat a broad range of severe tissue defects when using recipient vessels was not feasible (Zhang et al, 2012a; Bali et al, 2020; Bishop et al, 2018; Cipriani et al, 1999; Ciudad et al, 2020; Gencel et al, 2016; Zhang et al, 2012b; Hamdi et al, 2000; Hodgkinson et al, 1994; Jin et al, 2022; Karşıdağ et al, 2011; Kesiktas et al, 2006; Lai et al, 1991; Lu et al, 2013; Manrique et al, 2018; Ninkovic et al, 2000; Osaki et al, 2022; Sengezer et al, 1997; Serel et al, 2006; Topalan & Ermis, 2001; Townsend, 1987; Turgut et al, 2010; Woo et al, 2006; Yu et al, 1983; Yu et al, 2012). In addition to soft tissue reconstruction, and in keeping with the first description of CLFF, authors such as Yu et al and Ciudad et al reported the inclusion of osseous components.…”

“…Despite the selective use of CLFFs, the literature reported successful outcomes in cases as varied as those involving pediatric patients (Topalan & Ermis, 2001; Tvrdek et al, 1995), patients with neuropathic foot ulcers (Hamdi et al, 2000), and patients with prior radiation (Bishop et al, 2018), suggesting this technique is useful in a wide range of settings. Meticulous preoperative counseling helps to foster realistic expectations and ensure patient participation during the recovery period (Zhang et al, 2012a; Bali et al, 2020; Bishop et al, 2018; Ciudad et al, 2020; Gencel et al, 2016; Zhang et al, 2012b; Hamdi et al, 2000; Lu et al, 2013; Manrique et al, 2018; Serel et al, 2006; Topalan & Ermis, 2001; Turgut et al, 2010; Woo et al, 2006; Yu et al, 2012).…”

Efficacy of a “provisional incision” for longitudinal flap division after free-flap surgery

“…Therefore, necrosis can be avoided if the blood flow from the recipient bed and the surrounding tissue is sufficient, despite blocking the blood flow from the vascular pedicle to the distal side by longitudinal division of the myocutaneous flap. 7 , 8 , 9 …”