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Chang C, Di Meglio F, Sorkin A, Jan WL, Chen HC. A Novel Approach to Optimize Length Preservation in Cross-Leg Vascular Bridge Flap by AV Shunting. J Reconstr Microsurg 2024; 40:e1-e2. [PMID: 37793433 DOI: 10.1055/a-2185-3653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Affiliation(s)
- Chad Chang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Filippo Di Meglio
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Policlinico "Umberto I" Rome, Sapienza University of Rome, Rome, Italy
| | - Alex Sorkin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan
- Department of Plastic Surgery, Shamir Medical Center, Tel Aviv, Israel
| | - Wei-Ling Jan
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Chi Chen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan
- International Center, China Medical University Hospital, Taichung, Taiwan
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Celie KB, Guo S, Raya J, Fahradyan A, Carey J, Salibian AA. The cross-leg free flap: A systematic review of the literature. Microsurgery 2024; 44:e31144. [PMID: 38342999 DOI: 10.1002/micr.31144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/07/2023] [Accepted: 12/19/2023] [Indexed: 02/15/2024]
Abstract
BACKGROUND Free tissue transfer is a mainstay treatment for lower extremity soft tissue injuries. When the traditional cross-leg flap cannot provide enough coverage, a cross-leg free flap (CLFF) is a limb-saving alternative. The aim of this study is to conduct a systematic review of the literature published on the CLFF. METHODS We conducted a systematic review of articles describing the CLFF, according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Inclusion criteria included articles with primary data on the CLFF. Exclusion criteria included those describing pedicled cross-leg flaps or lacking complete data. Data analysis was performed using SPSS 29.0. RESULTS Our review included 28 articles encompassing 130 patients who underwent free tissue transfer. Most were male (63.8%) with a mean age of 32.4 years. Latissimus dorsi was the most common flap type (30.0%), followed by vertical rectus myocutaneous (20.0%). Average flap size was 301.8 cm2 , with trauma in the lower third of the leg being the most common indication (73.1%). The contralateral posterior tibialis was the most common recipient artery (84.1%) followed by the anterior tibialis (9.5%). Complications included amputation (1.4%), partial graft loss, thrombosis, hematoma, prolonged pain, nonunion, and seroma; a forest plot was used to illustrate the low overall adverse events rate. Although bivariate analysis identified age, flap size, type, location, and donor site as variables significantly impacting the incidence of complications (p < .05), this was not sustained in a multivariate logistic regression model. CONCLUSION The CLFF remains an excellent option for limb salvage when a suitable recipient vessel is unavailable. Our review demonstrates 1.4% flap failure and an acceptable complication rate. While most cases in our review describe muscle flaps, we report a complex case of limb salvage using an unusually large anterolateral thigh flap.
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Affiliation(s)
- Karel-Bart Celie
- Division of Plastic and Reconstructive Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California, USA
| | - Sarah Guo
- University of Southern California, Keck School of Medicine, Los Angeles, USA
| | - Jessica Raya
- University of Southern California, Keck School of Medicine, Los Angeles, USA
| | - Artur Fahradyan
- Division of Plastic and Reconstructive Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California, USA
| | - Joseph Carey
- Division of Plastic and Reconstructive Surgery, University of Southern California, Keck School of Medicine, Los Angeles, California, USA
| | - Ara A Salibian
- Division of Plastic and Reconstructive Surgery, University of California Davis, School of Medicine, Sacramento, USA
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Hsieh HH, Shieh SJ. Reconstruction With Flow-Through Chimeric Anterolateral Thigh Flap Combining Vascularized Fibular Bone Graft for Extensive Composite Tissue Defect of the Forearm: A Case Report. Ann Plast Surg 2024; 92:S65-S69. [PMID: 38170985 DOI: 10.1097/sap.0000000000003758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
ABSTRACT The management of critical limb trauma is challenging because limb salvage is preferable to amputation. For upper limb reconstruction, the surgical restoration of functionality, and appearance, a multidisciplinary approach is needed. We report the case of an extensive composite tissue defect of the forearm caused by a machine-crushing injury that was repaired by a flow-through chimeric anterolateral thigh flap with a vascularized fibular graft. Reconstruction was performed as a single-stage procedure; no complications occurred, and both functional and aesthetic outcomes were satisfactory.
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Affiliation(s)
- Hua-Hsin Hsieh
- From the Division of Plastic and Reconstructive Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University
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Berkane Y, Kostyra DM, Chrelias T, Randolph MA, Lellouch AG, Cetrulo CL, Uygun K, Uygun BE, Bertheuil N, Duisit J. The Autonomization Principle in Vascularized Flaps: An Alternative Strategy for Composite Tissue Scaffold In Vivo Revascularization. Bioengineering (Basel) 2023; 10:1440. [PMID: 38136031 PMCID: PMC10740989 DOI: 10.3390/bioengineering10121440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/28/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Autonomization is a physiological process allowing a flap to develop neo-vascularization from the reconstructed wound bed. This phenomenon has been used since the early application of flap surgeries but still remains poorly understood. Reconstructive strategies have greatly evolved since, and fasciocutaneous flaps have progressively replaced muscle-based reconstructions, ensuring better functional outcomes with great reliability. However, plastic surgeons still encounter challenges in complex cases where conventional flap reconstruction reaches its limitations. Furthermore, emerging bioengineering applications, such as decellularized scaffolds allowing a complex extracellular matrix to be repopulated with autologous cells, also face the complexity of revascularization. The objective of this article is to gather evidence of autonomization phenomena. A systematic review of flap autonomization is then performed to document the minimum delay allowing this process. Finally, past and potential applications in bio- and tissue-engineering approaches are discussed, highlighting the potential for in vivo revascularization of acellular scaffolds.
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Affiliation(s)
- Yanis Berkane
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rennes University Hospital Center, Rennes University, 16 Boulevard de Bulgarie, 35000 Rennes, France (T.C.); (N.B.)
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, Boston, MA 02114, USA; (M.A.R.); (A.G.L.); (C.L.C.J.)
- Shriners Children’s Boston, 51 Blossom Street, Boston, MA 02114, USA; (K.U.); basa (B.E.U.)
- SITI Laboratory, UMR1236, INSERM, Rennes University, 2 Rue Henri le Guillou, 35000 Rennes, France
| | - David M. Kostyra
- Plastic Surgery Research Laboratory, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, Boston, MA 02114, USA;
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, Boston, MA 02114, USA
| | - Theodoros Chrelias
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rennes University Hospital Center, Rennes University, 16 Boulevard de Bulgarie, 35000 Rennes, France (T.C.); (N.B.)
| | - Mark A. Randolph
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, Boston, MA 02114, USA; (M.A.R.); (A.G.L.); (C.L.C.J.)
- Shriners Children’s Boston, 51 Blossom Street, Boston, MA 02114, USA; (K.U.); basa (B.E.U.)
- Plastic Surgery Research Laboratory, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, Boston, MA 02114, USA;
| | - Alexandre G. Lellouch
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, Boston, MA 02114, USA; (M.A.R.); (A.G.L.); (C.L.C.J.)
- Shriners Children’s Boston, 51 Blossom Street, Boston, MA 02114, USA; (K.U.); basa (B.E.U.)
| | - Curtis L. Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, Boston, MA 02114, USA; (M.A.R.); (A.G.L.); (C.L.C.J.)
- Shriners Children’s Boston, 51 Blossom Street, Boston, MA 02114, USA; (K.U.); basa (B.E.U.)
| | - Korkut Uygun
- Shriners Children’s Boston, 51 Blossom Street, Boston, MA 02114, USA; (K.U.); basa (B.E.U.)
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, Boston, MA 02114, USA
| | - Basak E. Uygun
- Shriners Children’s Boston, 51 Blossom Street, Boston, MA 02114, USA; (K.U.); basa (B.E.U.)
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, 50 Blossom Street, Boston, MA 02114, USA
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rennes University Hospital Center, Rennes University, 16 Boulevard de Bulgarie, 35000 Rennes, France (T.C.); (N.B.)
- SITI Laboratory, UMR1236, INSERM, Rennes University, 2 Rue Henri le Guillou, 35000 Rennes, France
| | - Jérôme Duisit
- Department of Plastic, Reconstructive and Aesthetic Surgery, Rennes University Hospital Center, Rennes University, 16 Boulevard de Bulgarie, 35000 Rennes, France (T.C.); (N.B.)
- IRIS Sud Hospitals, Rue Baron Lambert 38, 1040 Etterbeek, Belgium
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Berkane Y, Lellouch AG, Goudot G, Shamlou A, Filz von Reiterdank I, Goutard M, Tawa P, Girard P, Bertheuil N, Uygun BE, Randolph MA, Duisit J, Cetrulo CL, Uygun K. Towards Optimizing Sub-Normothermic Machine Perfusion in Fasciocutaneous Flaps: A Large Animal Study. Bioengineering (Basel) 2023; 10:1415. [PMID: 38136006 PMCID: PMC10740951 DOI: 10.3390/bioengineering10121415] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/23/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Machine perfusion has developed rapidly since its first use in solid organ transplantation. Likewise, reconstructive surgery has kept pace, and ex vivo perfusion appears as a new trend in vascularized composite allotransplants preservation. In autologous reconstruction, fasciocutaneous flaps are now the gold standard due to their low morbidity (muscle sparing) and favorable functional and cosmetic results. However, failures still occasionally arise due to difficulties encountered with the vessels during free flap transfer. The development of machine perfusion procedures would make it possible to temporarily substitute or even avoid microsurgical anastomoses in certain complex cases. We performed oxygenated acellular sub-normothermic perfusions of fasciocutaneous flaps for 24 and 48 h in a porcine model and compared continuous and intermittent perfusion regimens. The monitored metrics included vascular resistance, edema, arteriovenous oxygen gas differentials, and metabolic parameters. A final histological assessment was performed. Porcine flaps which underwent successful oxygenated perfusion showed minimal or no signs of cell necrosis at the end of the perfusion. Intermittent perfusion allowed overall better results to be obtained at 24 h and extended perfusion duration. This work provides a strong foundation for further research and could lead to new and reliable reconstructive techniques.
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Affiliation(s)
- Yanis Berkane
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Department of Plastic, Reconstructive, and Aesthetic Surgery, CHU de Rennes, Université de Rennes, 35000 Rennes, France; (P.G.); (N.B.); (J.D.)
- Shriners Children’s Boston, Boston, MA 02114, USA
- SITI Laboratory, UMR1236, INSERM, Université de Rennes, 35000 Rennes, France
| | - Alexandre G. Lellouch
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
- Innovative Therapies in Haemostasis, INSERM UMR-S 1140, University of Paris, 75006 Paris, France
| | - Guillaume Goudot
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA;
- INSERM U970 PARCC, Université Paris Cité, 75000 Paris, France
| | - Austin Shamlou
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Irina Filz von Reiterdank
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02115, USA
- University Medical Center Utrecht, 3584 Utrecht, The Netherlands
| | - Marion Goutard
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
- SITI Laboratory, UMR1236, INSERM, Université de Rennes, 35000 Rennes, France
| | - Pierre Tawa
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Paul Girard
- Department of Plastic, Reconstructive, and Aesthetic Surgery, CHU de Rennes, Université de Rennes, 35000 Rennes, France; (P.G.); (N.B.); (J.D.)
| | - Nicolas Bertheuil
- Department of Plastic, Reconstructive, and Aesthetic Surgery, CHU de Rennes, Université de Rennes, 35000 Rennes, France; (P.G.); (N.B.); (J.D.)
- SITI Laboratory, UMR1236, INSERM, Université de Rennes, 35000 Rennes, France
| | - Basak E. Uygun
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02115, USA
| | - Mark A. Randolph
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Jérôme Duisit
- Department of Plastic, Reconstructive, and Aesthetic Surgery, CHU de Rennes, Université de Rennes, 35000 Rennes, France; (P.G.); (N.B.); (J.D.)
- Iris South Hospitals, 1040 Brussels, Belgium
| | - Curtis L. Cetrulo
- Division of Plastic and Reconstructive Surgery, Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, MA 02114, USA; (A.G.L.); (I.F.v.R.); (M.G.); (P.T.); (M.A.R.)
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
| | - Korkut Uygun
- Harvard Medical School, Boston, MA 02115, USA;
- Shriners Children’s Boston, Boston, MA 02114, USA
- Center for Engineering in Medicine and Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA 02115, USA
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Sabry M, Azmy MM, Darwish AMAA. Cross-leg flaps: Case series, review, and proposed classification. JPRAS Open 2023; 38:249-260. [PMID: 37954649 PMCID: PMC10637868 DOI: 10.1016/j.jpra.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/17/2023] [Indexed: 11/14/2023] Open
Abstract
Background Cross-leg (CL) flap procedures have a long history in reconstructive surgery, having been described for the first time in 1854. The application of these flaps can potentially solve many reconstructive issues with satisfactory outcomes. Patients and methods During our research into the history and development of CL flaps, we identified a variety of flaps for which a classification system can be proposed based on blood supply and flap modifications. In this study, 10 patients with different complaints were managed using posterior tibial artery (PTA) perforator CL flap and superiorly based sural CL flap with satisfactory outcomes. Results All flaps survived and healed smoothly; consequently, the flaps provided stable coverage, and the donor sites were reconstructed using skin grafts, which provided satisfactory results to the patients and/or their guardians. Conclusion To our knowledge, this is the first study to propose a simple classification and group different types of flaps mentioned in the literature under one category. CL flaps are a common reconstructive option for patients with injuries that limit their mobility.
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Affiliation(s)
- Mohamed Sabry
- Plastic and Reconstructive Surgery Department, Minia University Hospital, Minia, Egypt
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7
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Ciudad P, Escandón JM, Manrique OJ, Llanca L, Reynaga C, Mayer HF. Cross-leg free flaps and cross-leg vascular cable bridge flaps for lower limb salvage: experience before and after COVID-19. EUROPEAN JOURNAL OF PLASTIC SURGERY 2023; 46:1-11. [PMID: 37363691 PMCID: PMC10020769 DOI: 10.1007/s00238-023-02052-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/23/2023] [Indexed: 03/19/2023]
Abstract
Background Previous reports have evidenced the disruptive effect of the COVID-19 in microsurgical and reconstructive departments. We report our experience with cross-leg free flaps and (CLFF) and cross-leg vascular cable bridge flaps (CLVCBF) for lower limb salvage, technical consideration to decrease morbidity, and some structural modifications to our protocols for standard of care adapted to the COVID-19. Methods We retrospectively included consecutive patients undergoing reconstruction with CLFFs and CLVCBFs for lower limb salvage from January 2003 to May 2022. We extracted data on baseline demographic characteristics, mechanism of trauma, and surgical outcomes. Results Twenty-four patients were included, 11 (45.8%) underwent reconstruction with CLFF while 13 had CLVCBFs (54.2%). Fifteen patients (62.5%) underwent lower limb reconstruction under general anesthesia while 9 (37.5%) had combined spinal-epidural anesthesia. During COVID-19 pandemic, six CLFF cases were performed under S-E (25%). The average time for pedicle transection of muscle CLFFs and muscle CLVCBFs was comparable between groups (60 days versus 62 days, p = 0.864). A significantly shorter average time was evidenced for pedicle division of fasciocutaneous flaps in the CLFF group when compared to CLVCBFs (45 days versus 59 days, p = 0.002). Conclusions In selected patients, CLFFs and CLVCBFs offer an optimal alternative for lower limb salvage using recipient vessels out of the zone of injury from the contralateral limb. Modification in the surgical protocols can decrease improve resource allocation in the setting of severely ill patients during COVID-19.Level of evidence: Level III, Therapeutic.
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Affiliation(s)
- Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
- Institute of Plastic, Reconstructive and Aesthetic Surgery, Ciruesthetic, Clinic, Lima, Peru
| | - Joseph M. Escandón
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, NY USA
| | - Oscar J. Manrique
- Division of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, NY USA
| | - Lilyan Llanca
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - César Reynaga
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Horacio F. Mayer
- Department of Plastic Surgery, Hospital Italiano de Buenos Aires, University of Buenos Aires Medical School, Hospital Italiano de Buenos Aires University Institute (IUHIBA), Buenos Aires, Argentina
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8
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Kagaya Y, Ohura N, Miyamoto A, Ozaki M. Two stages of salvaging an extensively necrotic foot with chronic limb-threatening ischemia by arterialization of great saphenous vein and free latissimus dorsi musculocutaneous flap transfer for wound coverage with the arterialized vein as the recipient vessel: A case report. Microsurgery 2023; 43:166-170. [PMID: 36547018 DOI: 10.1002/micr.31001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 11/18/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
Patients with chronic limb-threatening ischemia (CLTI) without other options for adequate arterial revascularization could undergo deep (or distal) venous arterialization for limb salvage. Additionally, patients with extensive foot wound with CLTI sometimes require free flap transfer for limb salvage. We herein report a case of successful reconstructive limb-salvage surgery for an extensively necrotic foot with CLTI, using a two-stage operation involving venous arterialization using foot-perforating veins and subsequent free flap transfer (with preservation of the arterialized vein). The patient was a 59-year-old man with CLTI. The patient's right foot had dry necrotic tissue after Lisfranc joint amputation. Only one straight-line to the posterior tibial artery was achieved after endovascular therapies (four times). At the first stage of surgery, an arterial-venous shunt bypass from the superficial femoral artery to the distal great saphenous vein (GSV) (near the foot-perforating vein) was created. Arterial blood supply reached the necrotic area via the foot venous circulation system. At the second stage of surgery, free latissimus dorsi musculocutaneous flap (8 × 27 cm) transfer with preservation of the arterialized vein was performed. The pedicle artery was anastomosed to the bypass graft (end-to-side). The pedicle vein was anastomosed to the proximal stump of the GSV (end-to-end). The flap and residual foot survived completely, at a one-year follow-up postoperatively. An indocyanine green bypass-through angiography revealed the angiosome through the venous arterialization bypass graft, which included the flap; entire forefoot; and partial regions of the midfoot and heel. This two-stage operation might be considered a useful option for limb-salvage and complete wound-healing in patients with severe non-healing wound with CLTI. The two methods could compensate and overcome the problems of either method: incomplete wound-healing after venous arterialization, and the absence of a recipient artery for free flap transfer.
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Affiliation(s)
- Yu Kagaya
- Department of Plastic and Reconstructive Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Norihiko Ohura
- Department of Plastic and Reconstructive Surgery, Kyorin University Hospital, Tokyo, Japan
| | - Akira Miyamoto
- Department of Cardiovascular Medicine, Takatsu Chuo Hospital, Kanagawa, Japan
| | - Mine Ozaki
- Department of Plastic and Reconstructive Surgery, Kyorin University Hospital, Tokyo, Japan
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9
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钟 林, 何 亮, 尹 东, 金 哲, 牛 杨, 王 子, 黄 俊, 周 涛, 周 定, 周 洪. [Application of anterolateral thigh bridge flap with free skin graft wrapping vascular bridge in complex calf soft tissue defects]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2022; 36:619-624. [PMID: 35570638 PMCID: PMC9108651 DOI: 10.7507/1002-1892.202201093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/02/2022] [Indexed: 06/15/2023]
Abstract
Objective To explore the effectiveness of anterolateral thigh bridge flap with free skin graft wrapping vascular bridge in repairing complex calf soft tissue defects. Methods The clinical data of 11 patients with complex calf soft tissue defects between April 2018 and October 2021 were retrospectively analyzed, including 9 males and 2 females, aged 11-60 years, with a median age of 39 years. There were 8 cases of calf soft tissue defect caused by traffic accident, and 3 cases of calf skin infection caused by chronic osteomyelitis. The skin and soft tissue defects ranged from 10 cm×8 cm to 35 cm×10 cm after thorough debridement and accompanied with bone and tendon exposure. There was only one main vessel in calf of 9 cases and no blood vessel that could be anastomosed with the flap vessel could be found in the recipient site of 2 cases. The anterolateral thigh skin flap (the flap size ranged from 12 cm×10 cm to 37 cm×12 cm) was taken to repair the soft tissue defect. The donor site of the flap was treated with direct suture (8 cases) or partial suture followed by skin grafting (3 cases), and the vascular bridge was wrapped with medium-thickness skin graft. Results The flaps of 11 patients survived completely without necrosis, infection, and vascular crisis. The blood supply of the vascular bridge was unobstructed and the pulse was good. The color of the medium-thickness skin graft were ruddy. All 11 patients were followed up 2-40 months, with an average of 19.4 months. The flaps healed well with the surrounding tissues without obvious exudation and color difference. The flaps had normal color and temperature, good blood supply, and soft texture. The shape of the flap and calf contour were satisfactory and the function of the limb recovered well. The donor area of thigh flap healed by first intention without obvious scar formation. The donor area of skin healed well with a longitudinal oblong scar only and the appearance was satisfactory. Conclusion The anterolateral thigh bridge flap transplantation with free skin wrapping vascular bridge is an effective method for the treatment of complex calf soft tissue defects.
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Affiliation(s)
- 林 钟
- 安徽医科大学第一附属医院显微手足修复重建骨科(合肥 230022)The Microscopic Repair and Reconstruction Department of Hand and Foot, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230022, P. R. China
| | - 亮 何
- 安徽医科大学第一附属医院显微手足修复重建骨科(合肥 230022)The Microscopic Repair and Reconstruction Department of Hand and Foot, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230022, P. R. China
| | - 东 尹
- 安徽医科大学第一附属医院显微手足修复重建骨科(合肥 230022)The Microscopic Repair and Reconstruction Department of Hand and Foot, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230022, P. R. China
| | - 哲 金
- 安徽医科大学第一附属医院显微手足修复重建骨科(合肥 230022)The Microscopic Repair and Reconstruction Department of Hand and Foot, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230022, P. R. China
| | - 杨 牛
- 安徽医科大学第一附属医院显微手足修复重建骨科(合肥 230022)The Microscopic Repair and Reconstruction Department of Hand and Foot, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230022, P. R. China
| | - 子富 王
- 安徽医科大学第一附属医院显微手足修复重建骨科(合肥 230022)The Microscopic Repair and Reconstruction Department of Hand and Foot, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230022, P. R. China
| | - 俊 黄
- 安徽医科大学第一附属医院显微手足修复重建骨科(合肥 230022)The Microscopic Repair and Reconstruction Department of Hand and Foot, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230022, P. R. China
| | - 涛 周
- 安徽医科大学第一附属医院显微手足修复重建骨科(合肥 230022)The Microscopic Repair and Reconstruction Department of Hand and Foot, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230022, P. R. China
| | - 定 周
- 安徽医科大学第一附属医院显微手足修复重建骨科(合肥 230022)The Microscopic Repair and Reconstruction Department of Hand and Foot, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230022, P. R. China
| | - 洪翔 周
- 安徽医科大学第一附属医院显微手足修复重建骨科(合肥 230022)The Microscopic Repair and Reconstruction Department of Hand and Foot, the First Affiliated Hospital of Anhui Medical University, Hefei Anhui, 230022, P. R. China
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10
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Zhou HX, He L, Yin D, Niu Y, Jin Z, Li JJ, Wang QK, Zhou T. Modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure for complex lower extremity reconstruction. J Orthop Surg Res 2022; 17:262. [PMID: 35549724 PMCID: PMC9097098 DOI: 10.1186/s13018-022-03155-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 05/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Complex lower limb reconstruction due to severe trauma remains a challenge for reconstructive surgeons. Here, we introduce a modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure and evaluate its clinical efficacy. METHODS Between January 2013 and December 2019, 22 patients (range 10 to 64 years old) with unilateral lower limb injury underwent modified donor blood flow-preserved cross-leg anterolateral thigh flap procedures. Among them, 16 cases were traffic accidents, 5 cases were persistent ulcers, and 1 case was a degloving injury. The arterial pedicle of the flap was prepared in a Y-shaped fashion and microanastomosed to the posterior tibial artery of intact leg in a flow-through style. A split-thickness skin graft was applied to wrap the vascular pedicle after anastomosis. The flap was designed in a single or bilobed fashion according to the shape of the tissue defect. The operation time, the intraoperative blood loss and the length of hospital stays were recorded. The vascular pedicle was divided 4 weeks after anastomosis. Doppler ultrasound was performed to evaluate the blood flow of the donor posterior tibial artery during postoperative follow-up. RESULTS All 22 flaps survived. The tissue defects ranged from 12 × 6 to 21 × 18 cm2. The flap sizes ranged from 14 × 7.5 to 24 × 21 cm2. The average operation time, intraoperative blood loss and length of hospital stays were 6.73 ± 1.49 h, 280.95 ± 59.25 ml and 30.55 ± 2.52 days, respectively. Eighteen flaps were designed in a single fashion, while four were in bilobed fashion. Twenty patients underwent fasciocutaneous flap transplantations, while two underwent musculocutaneous flap transplantations. Two cases developed local lysis of the flap which healed after further debridement. Direct suture of the incision after flap harvest was performed in 16 cases, while additional full-thickness skin grafting was performed in the remaining 6 cases. Further bone transport procedures were performed in 15 patients who had severe tibia bone defects. The blood flow of donor posterior tibial artery was confirmed in all patients during follow-ups. All patients recovered flap sensation at the final follow-up. The postoperative follow-ups ranged from 18 to 84 months, and no long-term complications were observed. CONCLUSIONS The modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure is an ideal method to repair severe lower limb trauma with tibial artery occlusion which avoids sacrificing the major artery of the uninjured lower limb.
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Affiliation(s)
- Hong-Xiang Zhou
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Hefei, 230022, Anhui, China.
| | - Liang He
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Hefei, 230022, Anhui, China
| | - Dong Yin
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Hefei, 230022, Anhui, China
| | - Yang Niu
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Hefei, 230022, Anhui, China
| | - Zhe Jin
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Hefei, 230022, Anhui, China
| | - Jun-Jie Li
- Department of Orthopedics, The Fuyang People's Hospital of Anhui Medical University, Anhui, China
| | - Qian-Kun Wang
- Department of Orthopedics, The Fuyang People's Hospital of Anhui Medical University, Anhui, China
| | - Tao Zhou
- Department of Orthopedics, The First Affiliated Hospital of Anhui Medical University, No. 218, Jixi Road, Hefei, 230022, Anhui, China
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11
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Jin W, Chang S, Zhang Z, Wu X, Wu B, Qi J, Wei Z. Parallel Cross-Leg Free Flap with Posterior Tibial Artery Perforator Pedicle Propeller Cable Bridge Flap for the Treatment of Lower Extremity Wounds: A Case Series Report. J INVEST SURG 2022; 35:1572-1578. [PMID: 35379071 DOI: 10.1080/08941939.2022.2058127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND A cross-leg flap can be used to treat severely injured lower limbs but associated with complications. Herein, we describe a technique of a parallel cross-leg free flap combined with posterior tibial artery perforator pedicle propeller cable bridge flap for the treatment of lower extremity wounds. METHODS The artery and veins of the free flap are anastomosed to the contralateral posterior tibial artery and vein, respectively. The vascular pedicle is wrapped with a posterior tibial artery perforator pedicle propeller flap. The legs are allowed to remain in a straight, relaxed position which is maintained with a bandage or Kirschner wire placed at the distal limbs. Pedicle division is performed around 21 days after flap creation, and the posterior artery is re-anastomosed and pedicled flap returned to its original position. RESULTS From June 2017 to March 2020, 7 patients with lower extremity wounds and tissue loss received reconstruction with this method. The recipient vessels for all flaps were the posterior tibial artery and vein. The average operation time was 5 hours. The average time to ambulation was 4 weeks, and the average follow-up time was 13.7 months. All flaps survived, and limb salvage was successful in all patients. Patients were not uncomfortable with the limbs held in position until pedicle division, and there were no complications. At the final follow-up, the function of all limbs was normal, and the esthetic appearance was acceptable to all patients. CONCLUSIONS The method described overcomes the disadvantages of traditional cross-leg flaps for the treatment.
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Affiliation(s)
- Wenhu Jin
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Shusen Chang
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Ziyang Zhang
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Xiangkui Wu
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Bihua Wu
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Jianping Qi
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
| | - Zairong Wei
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, Guizhou, China
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12
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Osaki T, Hasegawa Y, Tamura R, Fukui T, Oe K, Niikura T, Nomura T, Hashikawa K, Terashi H. Combined treatment using cross-leg free flap and the Masquelet technique: a report of two cases. Case Reports Plast Surg Hand Surg 2022; 9:99-104. [PMID: 35402656 PMCID: PMC8986292 DOI: 10.1080/23320885.2022.2039667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
We introduce a treatment that combines the cross-leg free flap with the Masquelet technique and describe two cases using this method for bone and soft tissue reconstruction. Both patients were successfully treated and ambulatory. This novel method can be safely performed using the delay technique, indocyanine-green angiography and near-infrared spectroscopy.
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Affiliation(s)
- Takeo Osaki
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yasuko Hasegawa
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Ryosuke Tamura
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Tomoaki Fukui
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Keisuke Oe
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Takahiro Niikura
- Department of Orthopaedic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Tadashi Nomura
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kazunobu Hashikawa
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hiroto Terashi
- Department of Plastic Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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13
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Hong JP, Kim HB, Park CJ, Suh HP. Using Duplex Ultrasound for Recipient Vessel Selection. J Reconstr Microsurg 2022; 38:200-205. [PMID: 35108731 DOI: 10.1055/s-0041-1740218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Among the many factors involved in reconstructive microsurgery, identifying a good recipient vessel is one of the key elements leading to a successful result. MATERIAL AND METHOD Multiple modalities have been used to identify recipient vessels from simple palpation of axial arteries to hand-held Doppler, duplex ultrasound, computed tomography angiograms, and other advanced techniques. Although these various modalities bring their own unique advantages, using the duplex ultrasound can provide far superior and real-time information based on the anatomy and physiology of the recipient vessel. RESULT Duplex ultrasound is a valuable and powerful tool for reconstructive surgeons who are interested in performing microsurgery or supermicrosurgery. CONCLUSION As we enter the era of individualized/customized reconstruction using superthin flaps, perforator-to-perforator anastomosis, and supermicrosurgery, understanding and becoming versatile with duplex ultrasound will be critical especially in choosing recipient vessels.
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Affiliation(s)
- Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyung Bae Kim
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Changsik John Park
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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14
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Ciudad P, Vargas MI, Castillo-Soto A, Sanchez JR, Manrique OJ, Bustos SS, Forte AJ, Huayllani MT, Soto Z, Grández-Urbina JA. Manejo de heridas traumáticas de difícil cicatrización con colgajos microvasculares. J Wound Care 2021; 29:27-34. [PMID: 33048015 DOI: 10.12968/jowc.2020.29.sup10.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Present different flap alternatives when performing microvascular free-flap reconstruction in acute hard-to-heal wounds. METHOD A retrospective review of patients whose acute hard-to-heal wounds were treated with microvascular free-flap reconstruction. Data on demographics, wound aetiology, diagnostic, previous treatment, free-flap type, free-flap size, complications and follow up were analysed. RESULTS A total of 20 patients received microvascular free-flap reconstruction. The median age was 39.5 years. Twenty free-flap reconstructions were performed. These included: 3 cross-leg free flap, 1 cross-leg vascular cable bridge flap, 2 fibula osteocutaneous flap, 6 anterolateral thigh (ALT) flap, 3 thoracodorsal artery perforator (TDAP) flap, 3 fasciomyocutaneous flap, and 2 femoral artery fasciocutaneous flap. A patient required microvascular anastomosis due to hematoma; the rest did not present complications during their postoperative. Previous treatment included negative pressure wound therapy (12 patients) and surgical debridement with silver hydrogel dressings (8 patients). CONCLUSION Hard-to-heal wounds can be unresponsive to traditional wound healing practices or local flaps. They often require free-flap reconstruction, using tissues similar to those compromised. Microvascular techniques can be an effective alternative.
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Affiliation(s)
- Pedro Ciudad
- Departmento de Cirugía Plástica, Reconstructiva y Quemaduras, Hospital Nacional Arzobispo Loayza, Lima, Perú.,División de Cirujía Plástica, China Medical University Hospital, Taichung, Taiwan
| | - Maria I Vargas
- Departmento de Cirugía Plástica, Reconstructiva y Quemaduras, Hospital Nacional Arzobispo Loayza, Lima, Perú
| | - Ana Castillo-Soto
- Facultad de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Perú
| | | | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, Estados Unidos
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, Estados Unidos
| | - Antonio J Forte
- División de Cirugía Plástica y Reconstructiva, Mayo Clinic, Jacksonville, Florida, Estados Unidos
| | - Maria T Huayllani
- División de Cirugía Plástica y Reconstructiva, Mayo Clinic, Jacksonville, Florida, Estados Unidos
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15
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New Technique for the Proximal Leg Reconstruction: Medial Sural Artery-Based Cross-leg Flap. Indian J Orthop 2021; 55:481-485. [PMID: 34306564 PMCID: PMC8275715 DOI: 10.1007/s43465-021-00411-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/24/2021] [Indexed: 02/04/2023]
Abstract
Reconstruction of the lower extremity, especially the proximal lower leg, is known to be a challenge for reconstructive surgeons. When there is extensive vascular damage, the use of local flaps and microsurgical methods will be limited, so there are few reconstructive options available. We want to define the use of medial sural artery-based cross-leg flap for the reconstruction of the proximal lower leg. A 51-year-old male had a soft tissue defect on the proximal leg region because of a gun-shot injury. We observed that there was no chance of a local flap as a result of CT angiography. We considered free flap to be risky because of extensive vascular damage and medial sural artery-based cross-leg flap was planned. 12*20-cm-sized medial sural artery-based cross-leg flap was elevated from the contralateral leg and adapted to the defect without tension. Medial sural artery-based flap is mostly used as a vascular island for the reconstruction of knee defects. However, its use as a cross-leg flap has not been found in the literature. We believe that it is a safe option to consider in challenging cases such as after flap failure or patients not suitable for a free flap.
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16
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Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity. Ann Plast Surg 2021; 84:238-245. [PMID: 31513085 DOI: 10.1097/sap.0000000000001977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.
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17
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Ciudad P, Vargas MI, Castillo-Soto A, Sanchez JR, Manrique OJ, Bustos SS, Forte AJ, Huayllani MT, Soto Z, Grández-Urbina JA. Manejo de heridas traumáticas de difícil cicatrización con colgajos microvasculares. J Wound Care 2020; 29:27-34. [PMID: 33054617 DOI: 10.12968/jowc.2020.29.latam_sup_2.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Present different flap alternatives when performing microvascular free-flap reconstruction in acute hard-to-heal wounds. METHOD A retrospective review of patients whose acute hard-to-heal wounds were treated with microvascular free-flap reconstruction. Data on demographics, wound aetiology, diagnostic, previous treatment, free-flap type, free-flap size, complications and follow up were analysed. RESULTS A total of 20 patients received microvascular free-flap reconstruction. The median age was 39.5 years. Twenty free-flap reconstructions were performed. These included: 3 cross-leg free flap, 1 cross-leg vascular cable bridge flap, 2 fibula osteocutaneous flap, 6 anterolateral thigh (ALT) flap, 3 thoracodorsal artery perforator (TDAP) flap, 3 fasciomyocutaneous flap, and 2 femoral artery fasciocutaneous flap. A patient required microvascular anastomosis due to hematoma; the rest did not present complications during their postoperative. Previous treatment included negative pressure wound therapy (12 patients) and surgical debridement with silver hydrogel dressings (8 patients). CONCLUSION Hard-to-heal wounds can be unresponsive to traditional wound healing practices or local flaps. They often require free-flap reconstruction, using tissues similar to those compromised. Microvascular techniques can be an effective alternative.
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Affiliation(s)
- Pedro Ciudad
- Departmento de Cirugía Plástica, Reconstructiva y Quemaduras, Hospital Nacional Arzobispo Loayza, Lima, Perú.,División de Cirujía Plástica, China Medical University Hospital, Taichung, Taiwan
| | - Maria I Vargas
- Departmento de Cirugía Plástica, Reconstructiva y Quemaduras, Hospital Nacional Arzobispo Loayza, Lima, Perú
| | - Ana Castillo-Soto
- Facultad de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Perú
| | | | - Oscar J Manrique
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, Estados Unidos
| | - Samyd S Bustos
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, Estados Unidos
| | - Antonio J Forte
- División de Cirugía Plástica y Reconstructiva, Mayo Clinic, Jacksonville, Florida, Estados Unidos
| | - Maria T Huayllani
- División de Cirugía Plástica y Reconstructiva, Mayo Clinic, Jacksonville, Florida, Estados Unidos
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18
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Chen CY, Chiu YC, Hsu CE. Reconstruction of Gustilo type IIIC tibial open fracture caused by shotgun injury using combination Masquelet technique and cross-leg pedicle flap. Int J Surg Case Rep 2020; 72:391-396. [PMID: 32563828 PMCID: PMC7306524 DOI: 10.1016/j.ijscr.2020.06.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 11/24/2022] Open
Abstract
The treatment of open fracture combined with artery injury is challenging. In case a free flap is contraindicated, the cross-leg flap is a good optein. Masquelet technique is a promising treatment for bone defect with artery injury.
Introduction The shotgun injury may cause large-scale bone and soft tissue destruction especially when people get shot from a very close range. Here we present a case of Gustilo type IIIC open fractures of the proximal tibia with vascular injury, large bone and soft tissue defect treated with Masquelet technique in combination with cross-leg pedicle flap. Presentation of case A 34-year-old man presented with open proximal tibial fracture of Gustilo type IIIC, AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) classification 41-C2.3, caused by a shotgun injury from very close range (2 m). The wound was complicated with anterior tibial artery injury and segmental bone loss. After radical debridement, the fracture was temporarily stabilized with external fixator, followed by double plate fixation with cement spacer filled into the bone defect in accordance with the Masquelet technique. The soft tissue defect was covered with a cross-leg pedicle flap. At 3 months after trauma, the cement spacer was replaced by mixed autologous and synthetic bone graft. The fracture had successfully healed by 12 months after trauma. Discussion When the integrity of lower leg vessels is doubtful, the Masquelet technique in combination with cross-leg pedicle flap is an effective and safe alternative treatment for this condition. Conclusion We recommend to manage Gustilo type IIIC open fractures of the proximal tibia with bone defect with Masquelet technique in combination with cross-leg pedicle flap especially when the free flap technique is relatively contraindicated or trauma surgeon is not a highly-skilled microsurgeon.
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Affiliation(s)
- Chun-Yen Chen
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung, 40447, Taiwan.
| | - Yung-Cheng Chiu
- Department of Orthopedic Surgery, China Medical University Hospital, Taichung, 40447, Taiwan; School of Medicine, China Medical University, Taichung, 40447, Taiwan.
| | - Cheng-En Hsu
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan; Sports Recreation and Health Management Continuing Studies-Bachelor's Degree Completion Program, Tunghai University, Taichung, 407, Taiwan.
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19
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Bali ZU, Karatan B, Tuluy Y, Kececi Y, Yoleri L. Preserving the Blood Flow of the Recipient Artery in Cross-Leg Free Flap Procedure for Lower Extremity Reconstruction. INT J LOW EXTR WOUND 2020; 19:255-261. [DOI: 10.1177/1534734620913414] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
When there is no suitable vessel in the injured leg for microsurgical transfer, cross-leg free flaps can be considered for lower extremity reconstruction. This report describes patients who experienced lower extremity trauma and underwent reconstruction with cross-leg free flaps with preserved blood flow in the recipient artery. Anterolateral thigh flap is preferred for small to moderate defects. The descending branch of the lateral femoral circumflex artery was dissected 2 cm proximally and distally and was prepared in a T-shape. The branches of the T were anastomosed to the recipient artery in the contralateral leg in the first session of the cross-leg free flap procedure. After 3 weeks, the flap artery was separated from the bifurcation. For large defects, the latissimus dorsi flap was chosen. The thoracodorsal artery was anastomosed to the contralateral posterior tibial artery in the first session. After 3 weeks, to provide recipient vessel integrity, the thoracodorsal artery was transected from the flap and anastomosed to the distal stump of the posterior tibial artery. Between January 2017 and January 2019, 8 defects were reconstructed using an anterolateral thigh flap; the remaining 4 defects were reconstructed using a latissimus dorsi flap. All flaps survived without complications. Anterograde flow distal to the anastomosis was confirmed in all recipient arteries via Doppler ultrasound. In cross-leg free flaps, the continuity of the recipient artery can be established to prevent diminished blood flow to the recipient extremity.
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Affiliation(s)
| | - Berrak Karatan
- Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
| | - Yavuz Tuluy
- Manisa Celal Bayar University, Manisa, Turkey
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20
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Hong JP, Park CJ, Suh HP. Importance of Vascularity and Selecting the Recipient Vessels of Lower Extremity Reconstruction. J Reconstr Microsurg 2020; 37:83-88. [PMID: 32252097 DOI: 10.1055/s-0040-1708835] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Successful lower extremity reconstruction using free flaps begins by identifying a good recipient vessel and understanding the surrounding environment of the defect. METHODS One should consider multiple factors when selecting the recipient vessel such as the status of the axial arteries, trying to preserve flow as much as possible, extent and severity of the defect, and ultimately what type of anastomosis will be ideal. RESULTS Multiple factors of importance are reviewed and show the relevance in decision making and provide an algorithm. CONCLUSION In addition to the multiple factors to be considered, the ultimate decision should be made on the table during surgery when the actual artery or vein is exposed and shows signs of good pulsation and flow.
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Affiliation(s)
- Joon Pio Hong
- Department of Plastic Surgery, ASAN Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Changsik John Park
- Department of Plastic Surgery, ASAN Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyunsuk Peter Suh
- Department of Plastic Surgery, ASAN Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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21
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Pafitanis G, Elia R, Miller R, Wu CH, Ciudad P, Chen HC. The use of cross-limb venous bridge in extremity reconstruction of soft tissue defects following surgical excision of chronic wound. Microsurgery 2019; 39:278-279. [PMID: 30666709 DOI: 10.1002/micr.30416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 11/12/2018] [Accepted: 12/04/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Georgios Pafitanis
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Group for Academic Plastic Surgery, Queen Mary University of London, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Rossella Elia
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.,Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari, Italy
| | - Robert Miller
- Group for Academic Plastic Surgery, Queen Mary University of London, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Cho-Han Wu
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
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22
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Cross-leg latissimus dorsi free flap with chimeric serratus anterior bridge for lower extremity trauma: Case report and reconstructive algorithm. J Clin Orthop Trauma 2019; 10:867-872. [PMID: 31528059 PMCID: PMC6739264 DOI: 10.1016/j.jcot.2019.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 11/22/2022] Open
Abstract
Gustilo Grade IIIB and IIIC open fractures of the lower extremity often involve complex wounds requiring bony fixation and soft tissue reconstruction. We present a case of a 32 year-old male who suffered a traumatic Gustilo Grade IIIB open fracture of the tibia and fibula with an extensive soft tissue defect. Reconstruction was first attempted with a turbocharged anterolateral thigh flap that failed due to venous thrombosis. Due to vascular injury, limited reconstructive options were available from the ipsilateral leg. Limb salvage was subsequently achieved with a chimeric cross-leg latissimus dorsi-serratus anterior (LD-SA) free flap based off the contralateral healthy leg, using the serratus for pedicle bridge coverage so that the latissimus could be fully used for defect coverage. Though not extensively described in the literature, this flap is a versatile reconstructive option for limb salvage in patients with Gustilo IIIB or IIIC injuries to the lower extremity.
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