Microsurgical free muscle flaps for reconstruction of post-traumatic complex tissue defects of foot

The esthetic outcome of recipient sites of gracilis muscle flaps versus anterolateral thigh flaps: A retrospective study

BACKGROUND

Anterolateral thigh (ALT) and gracilis muscle flaps have been described as comparable reconstructive options regarding maximal flap dimension and indications. However, split-thickness skin-grafted muscle flaps are generally believed to be inferior to perforator flaps regarding the esthetic outcome of the recipient site. The purpose of this study was to challenge this assumption, comparing the long-term esthetic outcome of the gracilis and the ALT flap.

METHODS

One hundred forty-eight patients who had undergone free flap reconstruction with either free split-thickness skin-grafted gracilis muscle flaps (n = 86) or ALT flaps (n = 62) were evaluated in the study. Patients' satisfaction with the esthetic outcome, rates of flap loss, wound healing disorders and the necessity for thinning the flap or scar correction procedures were assessed.

RESULTS

Flap loss occurred in 4 of 86 gracilis flaps (4.7%) and 2 of 62 (3.2%) ALT flaps (p > .9999). Thinning or scar correction procedures were necessary for 6 of 86 gracilis (7.0%) and 4 of 62 (6.5%; p > .9999) ALT flap recipient sites. Regarding the overall patients' satisfaction with the esthetic outcome, scores were similar in both groups (2.667 [ALT] vs. 2.348 [gracilis]; p = .3739). Contour deformity, scar hypertrophy, and difference in flap color/texture in relation to the surrounding skin were comparable throughout the ALT and gracilis group (2.667 vs. 2.174, p = .2099; 3.333 vs. 2.739, p = .0912 and 2.500 vs. 2.174, p = .3159, respectively).

CONCLUSION

The gracilis and ALT flap are two equivalent reconstructive options regarding the esthetic outcome of the recipient site and long-term patient satisfaction.

RB. Outcome Analysis Comparing Muscle and Fasciocutaneous Free Flaps for Heel Reconstruction: Meta-Analysis and Case Series

Background Choosing the components of free flap (fasciocutaneous or muscle) is one of the crucial but controversial decisions in heel reconstruction. This meta-analysis aims to provide an up-to-date comparison of fasciocutaneous flaps (FCFs) and muscle flaps (MFs) for heel reconstruction and to ascertain if one flap has an advantage over the other.

Methods Following the Preferred Reporting Item for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was performed identifying studies on heel reconstruction with FCF and MF. Primary outcomes were survival, time of ambulation, sensation, ulceration, gait, need for specialized footwear, revision procedures, and shear. Meta-analyses and Trial Sequential Analysis (TSA) were performed to estimate the pooled risk ratios (RRs) and standardized mean difference (SMD) with fixed effects and random effects models, respectively.

Results Of 757 publications identified, 20 were reviewed including 255 patients with 263 free flaps. The meta-analysis showed no statistically significant difference between MF and FCF in terms of survival (RR, 1; 95% confidence interval [CI], 0.83, 1.21), gait abnormality (RR, 0.55; 95% CI, 0.19, 1.59), ulcerations (RR, 0.65; 95% CI, 0.27, 1.54), footwear modification (RR, 0.52; 95% CI, 0.26, 1.09), and revision procedures (RR, 1.67; 95% CI, 0.84, 3.32). FCF had superior perception of deep pressure (RR, 1.99; 95% CI, 1.32, 3.00), light touch, and pain (RR, 5.17; 95% CI, 2.02, 13.22) compared with MF. Time to full weight-bearing (SMD, –3.03; 95% CI, –4.25, –1.80) was longer for MF compared with FCF. TSA showed inconclusive results for comparison of the survival of flaps, gait assessment, and rates of ulceration.

Conclusion Patients reconstructed with FCF had superior sensory recovery and early weight bearing on their reconstructed heels, hence faster return to daily activities compared with MFs. In terms of other outcomes such as footwear modification and revision procedure, both flaps had no statistically significant difference. The results were inconclusive regarding the survival of flaps, gait assessment, and rates of ulceration. Future studies are required to investigate the role of shear on the stability of the reconstructed heels.

Foot salvage using microsurgical free muscle flaps in severely crushed foot with soft tissue defects

OBJECTIVE

Management of complex foot injuries including skin, tendons, vessels, bone, with soft tissue defects is considered as an orthopedic challenge. Microsurgical free muscle flaps provide the best solution in such cases.

PATIENTS AND METHODS

Thirty two consecutive cases of complex ankle and foot injuries were treated by skin grafted muscle free flap in one stage procedure after radical debridement. Twenty four were males and 8 were females. Right foot was affected in 26 and left was involved in 6 patients. The average age was 22 years (range 6-33 years). The most common cause of injury was motor car accident. All cases had complex soft tissue defect with bone exposure. All cases were candidate for amputation. Gracilis muscle transfer was done in 26 cases and latissimus dorsi free flap in 6 cases. The average follow up was 38 months.

RESULTS

All the free muscle flaps survived. The involved bone fracture was united at an average 3 months. No evidence of osteomyelitis was noted. Full weight bearing was restored 3 months post-operatively. All patients were satisfied with the cosmetic appearance and functional capacity of their operated limbs.

CONCLUSION

Skin-grafted free muscle flap as one-stage procedure is a good solution for reconstruction of complex ankle and foot injuries.