Striving for Normalcy after Lower Extremity Reconstruction with Free Tissue: The Role of Secondary Esthetic Refinements

Nelson, Jonas A.; Fischer, John P.; Haddock, Nicholas T.; Mackay, Duncan D. J.; Wink, Jason D.; Newman, Andrew S.; Levin, L. Scott; Kovach, Stephen J.

doi:10.1055/s-0035-1558986

Cited by 21 publications

(27 citation statements)

References 30 publications

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“…14 To overcome this limitation, immediate debulking of ALT flaps elevated subfascially or suprafascially has been described prior to inset, especially among younger patients. 4 However, partial flap loss that is most likely explained by the interruption of the flap's microcirculation, may occur. 28,29 Microdissection techniques to improve flap safety are tedious and time consuming.…”

Section: Discussionmentioning

confidence: 99%

“…Primary and secondary debulking procedures have therefore been introduced and are widely used in many centers. 4 In primary thinning, relatively large fat lobules that lie deeply to the superficial fascia are removed after elevation of the flap. However, primary thinning may lead to partial loss of the flap when conducted too aggressively with the destruction of small veins.…”

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confidence: 99%

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Evaluation of the Suprafascial Thin ALT Flap in Foot and Ankle Reconstruction

Thiele

Weiss

Braig

et al. 2021

J Reconstr Microsurg

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Background Distal lower extremity reconstruction can be challenging in terms of flap design. Bulky flaps result in limited mobility accompanied with the need of customized footwear. Raising the ALT-flap in a superficial fascial plane (thin ALT-flap) can be beneficial. This study evaluates thin ALT-flaps for lower distal extremity reconstruction. Methods In a retrospective study, patients that underwent microvascular extremity reconstruction at the level of the ankle and dorsal foot at the University of Freiburg from 2008–2018 were reviewed. Results 95 patients could be included in the study (35 perforator flaps, 8 fascia flaps and 54 muscle flaps).Among the perforator flaps, 21 ALT-flaps were elevated conventionally and 14 in the superficial fascial plane (thin ALT-flap). Among the conventional ALT-flaps, there was one flap loss (5%) and one successful revision (5%). 5(24%) flaps received secondary thinning. 57%(n = 12) were able to wear conventional footwear. There were 2(15%) successful revisions of thin ALT-flaps. 100% of thin ALT-flaps survived and 85%(n = 11) of the patients wore ordinary footwear after defect coverage.Among fascial flaps, 50%(n = 4) had to be revised with 2(25%) complete and 1 (13%) partial flap loss. All patients achieved mobility in ordinary shoes (n = 8).In muscle flaps, there were 7(13%) revisions and 5(9%) flap losses. 5(9%) flaps received secondary thinning. Only 33%(n = 18) were mobile in ordinary footwear. Conclusion The thin ALT-flap is a save one-stage evolution for lower distal extremity reconstruction with a favorable flap survival rate. Compared with conventional ALT-flaps it might be beneficial in reducing the need for expensive custom fitted shoes and secondary thinning procedures.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Evaluation of the Suprafascial Thin ALT Flap in Foot and Ankle Reconstruction

Thiele

Weiss

Braig

et al. 2021

J Reconstr Microsurg

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“…They found that approximately 20% of their patients underwent secondary procedures to improve the contour and esthetics of the free flap. The procedures included complex local tissue rearrangement or debulking, direct scar excision, liposuction and laser scar treatment 15 . In our series, 4 patients (19%) out of the cohort that had successful lower extremity salvage ultimately underwent secondary debulking procedures.…”

Section: Discussionmentioning

confidence: 99%

“…However, despite its popularity, the ALT flap is not without limitations in the coverage of lower extremity defects. Specifically, in the treatment of small and medium sized defects of the lower extremity, the ALT flap often requires multiple secondary operations for flap debulking, as it does not atrophy over time 15 . Furthermore, for reconstruction of foot and ankle defects, the bulk of the ALT flap impairs aesthetic outcomes and hinders shoe and orthotic fitting which is a significant limitation for return to functional activity 15 .…”

Section: Introductionmentioning

confidence: 99%

Lower Extremity Reconstruction with Free Gracilis Flaps

Franco

Nicoson

Parikh

et al. 2016

J reconstr Microsurg

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Background There have been significant advancements in lower extremity reconstruction over the last several decades, and the plastic surgeon’s armamentarium has grown to include free muscle and fasciocutaneous flaps along with local perforator and propeller flaps. While we have found a use for a variety of techniques for lower extremity reconstruction, the free gracilis has been our workhorse flap due to the ease of harvest, reliability, and low donor site morbidity. Methods This is a retrospective review of a single surgeon’s series of free gracilis flaps utilized for lower extremity reconstruction. Demographic information, comorbidities, outcomes and secondary procedures were analyzed. Results We identified 24 free gracilis flaps. The duration from injury to free flap coverage was 7 days or less in 6 patients, 8–30 days in 11 patients, 31–90 days in 4 patients, and > 90 days in 3 patients. There were 22 (92%) successful flaps and an overall limb salvage rate of 92%. There was one partial flap loss. Two flaps underwent incision and drainage in the operating room for infection. Two patients developed donor site hematomas. Four patients underwent secondary procedures for contouring. Our subset of pediatric patients had 100% flap survival and no secondary procedures at a mean 30 month follow up. Conclusions This study demonstrates the utility of the free gracilis flap in reconstruction of small to medium sized defects of the lower extremity. This flap has a high success rate and low donor site morbidity. Atrophy of the denervated muscle over time allows for good shoe fit, often obviating the need for secondary contouring procedures.

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“…Nelson et al reported 21.1% of their 152 patients underwent secondary aesthetic revisions again with debulking being the most common procedure. 65 However, they did not compare fasciocutaneous versus muscle groups. In our experience, free muscle flaps with an unmeshed skin graft provide durable coverage and muscle atrophy leads to acceptable contouring if inset well at initial operation.…”

Section: Principles Of Surgical Treatmentmentioning

confidence: 99%

Management of Post-Traumatic Osteomyelitis in the Lower Limb: Current State of the Art

Chan

Ferguson

Scarborough

et al. 2019

Indian J Plast Surg

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Osteomyelitis (OM) of the lower limb represents a large unmet global healthcare burden. It often arises from a contiguous focus of infection and is a recognized complication of open fractures or their surgical treatment, arthroplasty, and diabetic foot ulcers. Historically, this debilitating condition is associated with high rates of recurrence and secondary amputation. However, excellent long-term outcomes are now achieved by adopting a multidisciplinary approach with meticulous surgical debridement, skeletal and soft tissue reconstruction, and tailored antimicrobial treatment. This review focuses on the modern evidence-based management of post-traumatic OM in the lower limb from a reconstructive plastic surgery perspective, highlighting the latest developments and areas of controversy.

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Striving for Normalcy after Lower Extremity Reconstruction with Free Tissue: The Role of Secondary Esthetic Refinements

Cited by 21 publications

References 30 publications

Evaluation of the Suprafascial Thin ALT Flap in Foot and Ankle Reconstruction

Evaluation of the Suprafascial Thin ALT Flap in Foot and Ankle Reconstruction

Lower Extremity Reconstruction with Free Gracilis Flaps

Management of Post-Traumatic Osteomyelitis in the Lower Limb: Current State of the Art

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