Skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage

Abstract

Aim: Free tissue transfer is essential for extremity reconstruction following traumatic injuries, oncologic resection, and diabetic complications. However, given the circumferential shape of the arm and leg, a small amount of ongoing edema can prevent a tension-free closure. Additionally, intraoperative thrombosis, vascular disease can lead to proximal exposure of the pedicle or vein grafts. This study evaluates the outcomes of microvascular transfers that utilized a skin graft for closure over the pedicle, in comparison with a matched cohort with a tension-free primary closure. Methods: A retrospective review was completed of all patients that underwent free flap reconstruction of an extremity defect from January 2014 to December 2017 at a single academic institution. Flaps that utilized skin grafting for closure were compared to those closed primarily. Adjunct operative procedures, demographics, and complications were evaluated. Results: A total of 71 patients fulfilled the inclusion criteria. The 11 flaps in 10 patients underwent skin grafting over the pedicle. The two cohorts were comparable in age, gender, BMI, and co-morbidities, excluding renal disease which was present in 40% (n = 4) of skin grafted group compared to 6.5% (n = 4) in the primary closure group. Flap area, operative time, and anastomosis technique were comparable between the two groups. There was no significant difference in the rates of post-operative complications including partial flap loss, complete flap loss, infection. Mean follow up time in the skin grafting group was 14.2 months and 20.2 months for the primary closure group. Conclusion: As per the principal, a tension-free closure is paramount to preventing tissue complications including direct compression of a microvascular pedicle. However, with ongoing tissue edema skin grafting should be considered as a reliable technique to ensure both protection of the pedicle as well as prevention of direct compression without additional complications and comparable post-operative outcomes.

Managing Vascular Pedicle Exposure in Free Tissue Transfer Using a Reprocessed Micronized Dermal Substitute in Lower Extremity Reconstructions

“…Han et al reported a graft take rate of 99.3% using an STSG over the exposed pedicle in 15 patients without flap compromise [ 16 ]. Kovar et al discussed the safety of skin grafts (i.e., split-andfull-thickness) over an exposed vascular pedicle [ 17 ]. No significant differences in flap outcomes (venous thrombosis, arterial insufficiency, flap loss, or dehiscence) were observed between the group in which primary closure was performed, and the group in which skin grafting was performed.…”

Commentary of ��skin grafting the vascular pedicle: a useful technique to avoid microvascular collapse in free tissue transfer for limb salvage��

“…We commend the authors on an excellent paper comparing the outcomes of microvascular transfers that utilized a skin graft for closure over the pedicle to a tension-free primary closure [1] . The retrospective cohort study of 71 patients found no significant difference in the rate of post-operative complications between the two groups.…”

“…We are grateful to Kovar et al [1] for shining insight on a very interesting topic and offering data on the use of skin grafting of the vascular pedicle. We do believe skin grafting should be used only as a last resort.…”