A Comprehensive Approach to Lower Extremity Free-tissue Transfer

Revisiting the reconstructive ladder for soft tissue reconstruction in the lower extremity

Soft tissue reconstruction of the lower limb has seen a paradigm shift over the past two decades. Typically, these defects arise from trauma, infection or tumor. It is no longer enough to simply achieve coverage. Factors like patient-reported outcomes and aesthetic considerations are essential in the decision-making process. This is especially in light of increasing technological advancement, availability of dermal substitutes, microsurgical expertise and development of the field of microsurgical reconstruction as a whole with more novel flaps and techniques. Advancements in reconstructive modalities have also been equally matched by better emergency medical mobilization, transportation and access, early initiation of subspecialty care, accessibility and types of imaging, as well as oncological advances in radiotherapy and chemotherapy regimens. Yet, this has also meant that our patient profile has expanded to include older patients with more co-morbidities and other considerations such as frailty or the irradiated field which could influence what reconstructive modality is suitable and the goals of reconstruction specific to the patient. Previously deemed unsalvageable limbs are now being successfully reconstructed with good function and aesthesis. In the lower limb, this implicates the ability for early mobilization, range of motion and weight bearing which allow the patient to successfully partake in early rehabilitation. Expedient and reliable healing is also important in the oncological population where a proportion of these patients would need to go on to receive post-operative chemotherapy or radiotherapy. The reconstructive ladder has been what many reconstructive surgeons have been taught upon with regard to the basic principles of pre-operative planning and choosing the appropriate reconstructive modality. In this article, we examine the relevance of the reconstructive ladder in modern practice and the additional considerations in the approach to a soft tissue defect in the lower extremity.

Lower Extremity Reconstruction with Anterolateral Thigh Free-Flap Anastomoses: A Computational Fluid Dynamic Analysis

BACKGROUND

 The anterolateral thigh free flap is an option for repairing soft tissue defects of the distal lower extremity. This flap uses the descending branch of the lateral circumflex femoral (LCF) artery as the flap vessel. The recipient vessel in these flaps is often the anterior tibial (AT), posterior tibial (PT), or peroneal (P) arteries. Computational fluid dynamic (CFD) evaluation of anastomoses between these vessels can optimize outcomes.

METHODS

 Thirty-eight CFD models were created to model end-to-side (ETS) and end-to-end (ETE) anastomoses for lower extremity reconstruction. Seven out of thirty-eight models represented ETS anastomoses between the LCF and AT arteries with varying anastomotic angles. Nine out of thirty-eight models represented 45-degree ETS anastomoses between varying diameters of the LCF and AT, PT, and P arteries. Nine out of thirty-eight models represented stenosis on the flap vessel and recipient vessel, pre- and post-bifurcation. Nine out of thirty-eight models represented ETE anastomoses, rather than ETS, with varying vessel diameters. Four out of thirty-eight models represented ETE anastomoses with varying regions and levels of stenosis.

RESULTS

 Stasis of blood flow in ETS models increased as anastomotic angle increased in a logarithmic relationship (R 2 = 0.918). Flow was optimized overall as flap and recipient vessel diameters approached one another. In ETS models, flap vessel and postbifurcation recipient vessel stenosis were found to substantially increase stasis.

CONCLUSION

 Selection of flap and recipient vessels with similar diameters can optimize outcomes in microvascular anastomoses. In the context of lower extremity reconstruction with the ALT flap, the PT artery can be recommended as a first-line recipient vessel due to its similar vessel caliber to the LCF and relative ease of surgical access compared with the P artery. Avoidance of areas of stenosis is recommended to ensure laminar flow and reduce the operative difficulty associated with performing anastomoses on nonpliable arteries. Striving for increased acuity of anastomotic angles is recommended to optimize the flow in ETS microvascular anastomoses.

A simple free flap strategy using end-to-side anastomosis to the main vessels in injured extremity

Background

During free flap surgery, the surgeon sometimes encounters problems with anastomosis such as intractable arterial spasms or vessel size discrepancy in venous anastomoses. End-to-side (ETS) anastomosis has the advantages of limited chance of vessel spasm and easy handling by adjusting for vessel size discrepancy. We introduced the arterial and venous end-to-side anastomosis (AV-ETS) strategy, which is based on the ETS anastomosis to the main artery and accompanying veins, to avoid intraoperative anastomotic problems when creating a free flap. The aim of this study was to compare flap outcomes and intraoperative anastomotic problems before and after introduction of the AV-ETS strategy in extremity free flap surgery.

Materials and methods

We retrospectively examined 72 consecutive extremity free flaps. Before introducing the AV-ETS strategy, we used the conventional strategy in which the recipient artery was selected according to the number of the remaining main artery and the anastomosis technique was flexibly changed, although the end-to-end (ETE) technique was used in most cases.

Results

The conventional group had 18 flaps and the AV-ETS group had 54 flaps. The rate of flap survival did not differ between these groups, and there were no cases of flap failure after the introduction of the AV-ETS strategy. The AV-ETS group had significantly fewer flaps that required a change in preoperative planning for the recipient artery or anastomotic site of the artery.

Conclusions

The AV-ETS strategy may facilitate reliable preoperative planning and the performance of stable free flap surgery without requiring a flexible response during surgery.

Evaluation of Intraoperative Anastomotic Patency with Angiography in Microsurgical Breast Reconstruction

Background

Microsurgical breast reconstruction is one of the most challenging, yet rewarding procedures performed by plastic surgeons. Several measures are taken to ensure safe elevation of the flap, preparation of recipient vessels, microvascular anastomosis, and flap inset. Reestablishing proper blood flow to the flap tissue after microvascular anastomosis is one of many critical steps for surgical success. Several measures to assess blood flow to the flap have been used; however, the use of indocyanine green angiography (ICGA) of the anastomosis in breast reconstruction has not been well documented. We present a series using ICGA for the evaluation of microvascular anastomosis success in breast reconstruction.

Methods

Cases from patients who underwent microsurgical breast reconstruction between March 2022 and January 2023 and who had intraoperative ICGA were retrospectively reviewed. We compared the intraoperative findings on ICGA to flap success.

Results

Sixteen patients underwent bilateral deep inferior epigastric perforator flap reconstruction with intraoperative ICGA of the microvascular anastomosis, constituting 32 deep inferior epigastric perforator flaps. The ICGA demonstrated return of blood flow in all the flaps after microvascular anastomosis and no flap loss in our sample population. Nine flaps required additional drainage using the superficial inferior epigastric vein, and the superficial circumflex vein was used for additional drainage in one of the flaps.

Conclusions

The use of intraoperative ICGA provides reliable visual feedback regarding the patency and direction of the blood flow through the microvascular anastomosed vessels. ICGA can be used as an additional tool in the plastic surgeon's armamentarium for successful breast reconstruction.

Reliability and Safety of Cross-Leg Free Latissmus Dorsi Muscle Flap in Reconstruction of Mutilating Leg Injuries Using End-to-Side Anastomosis

Background  Free tissue transfer is considered the gold standard option for the reconstruction of distal leg defects. Free tissue transfer using recipient vessels in the contralateral leg (cross-leg bridge) is a potential option to supply the flap if there are no suitable recipient vessels in the injured leg. Most studies have described this technique using end-to-end anastomosis which sacrifices the main vessel in the uninjured leg. This study evaluated the use of a cross-leg free latissimus dorsi muscle flap for the reconstruction of defects in single-vessel legs, using end-to-side anastomosis to recipient vessels in the contralateral leg without sacrificing any vessel in the uninjured leg. Methods  This is a retrospective study that included 22 consecutive patients with soft tissue defects over the lower leg. All the reconstructed legs had a single artery as documented by CT angiography. All patients underwent cross-leg free latissimus dorsi muscle flap using end-to-side anastomosis to the posterior tibial vessels of the contralateral leg. Results  The age at surgery ranged from 12 to 31 years and the mean defect size was 86 cm 2 . Complete flap survival occurred in 20 cases (91%). One patient had total flap ischemia. Another patient had distal flap ischemia. Conclusion  Cross-leg free latissimus dorsi muscle flap is a reliable and safe technique for the reconstruction and salvage of mutilating leg injuries, especially in cases of leg injuries with a single artery. As far as preservation of the donor limb circulation is concerned, end-to-side anastomosis is a reasonable option as it maintains the continuity of the donor leg vessels.

Late lower extremity free flap vascular compromise and salvage in a Pediatric patient diagnosed with monophasic synovial sarcoma

Free tissue flap transfer can be utilized for reconstruction following tumor resection. While flap failure occurs primarily within 72 h post-operation, late failure after day 7 is rare. We present the case of a 14-year-old with a late lower extremity free flap vascular compromise, along with the successful flap salvage.

Reoperative Microsurgical Free Flap Surgery: Lessons Learned

ABSTRACT

Microsurgical free flap surgery has revolutionized reconstructive surgery at most academic centers worldwide. However, free flap failures still occur even in the hands of the most experienced microsurgeon. Although we have achieved a great deal of success performing microsurgical free flap reconstruction for various indications, complications from initial free flap surgery that result in reoperation remain a small, but steady percentage. Venous flap congestion is one of the most challenging conditions that result in free flap failure if not resolved promptly. It can be caused by several conditions, and salvage for venous congestion is often difficult and time consuming. Over 20 years, the senior author has encountered 2 unique situations that resulted in venous congestion of the flap requiring reoperative surgery for flap salvage or a second free flap. Several medical conditions can compromise free flap surgery and result in total flap loss. The senior author has also encountered 2 medical conditions resulting in total flap loss. However, both patients received successful second free tissue transfers when combined with unique perioperative management strategies. It is our hope that this review will highlight some unique management strategies for reoperative microsurgical free tissue transfer and serve as "lessons learned" for initial salvage procedures and a second free tissue transfer. We also hope our reoperative approach demonstrated in this review will help the future generation of microsurgeons to avoid such complications altogether so that overall outcome after microsurgical free flap surgery can further be improved.

Timing of Unplanned Reoperation After Lower Extremity Free Flap Reconstruction: What Are the Roles of Procedure Indication and Defect Etiology?

BACKGROUND

Advancements in lower extremity (LE) microsurgery have allowed for the expansion of indications for LE reconstructions. This project aims to better understand the temporal pattern and risk factors associated with LE free flap failure based on the clinical indication.

MATERIALS AND METHODS

We analyzed all patients undergoing LE free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012-2019 prospectively collected data to determine rates and timing of reoperation. Free flaps were stratified by indication, type, and timing of reoperation. Weibull survival models were used to compare rates of takebacks among time intervals. Multivariable logistic regression was used to identify independent predictors for unplanned reoperation.

RESULTS

Four hundred seven of LE free flaps were analyzed. There was a 14.5% rate (59/407) of unplanned reoperation within the first 30 postoperative days (PODs) after surgery. When stratified by the indication necessitating reoperation, patients with an underlying vascular indication had the highest rate of reoperation (40.9%). The reoperation rates were significantly different between indications (P < 0.05) The mean daily proportion of patients experiencing reoperation was highest during POD 0 to 2 (1.47% reoperations per day), which dropped significantly during POD 3 to 10 (0.55% per day) and again during POD 11 to 30 (0.28% per day, P < 0.05). African American race as well as malignant, prosthetic/implant, and wound/infectious indications were significant independent predictors for unplanned reoperation.

CONCLUSIONS

Lower extremity reconstruction is an important reconstructive option for the coverage of a myriad of defects. Understanding the differences between postoperative reoperation timelines among indication subtypes is important for updated flap monitoring protocols, optimizing ERAS pathways, and beginning dangle protocols.

Comparison of Complication Risks Following Lower Extremity Free Flap Reconstruction Based on Seven Pre-Operative Indications: Analysis of the ACS-NSQIP Database

Background: Free tissue transfer is a valuable surgical option for the reconstruction of a myriad of complex lower extremity defects. Currently, there is a paucity of data that examines the risks of complications for each of these unique indications. Methods: Patients undergoing lower extremity free flap reconstruction from the ACS-NSQIP 2011–2019 database were stratified into groups based on the etiology and indication for reconstruction. Rates of major, surgical wound, and medical complications were compared over the first post-operative month. Multivariable logistic regression was used to identify complication predictors. Results: 425 lower extremity free flaps were analyzed. The most common indications for lower extremity free flap reconstruction were wound-related (29%), malignancy (21%), and trauma (17%). Seventeen percent of free flaps had a major post-operative complication, 9% had a surgical wound complication, and 16% had a medical complication. There were no significant differences in major complications between the indications. However, the independent risk factors for major complications varied widely. Those with an indication of malignancy and those who received a musculocutaneous free flap were significantly more likely to have a surgical wound complication compared to the remaining cohort ( p < 0.05). Those requiring free flap reconstruction for orthopedic hardware related concerns as well as those with wound related indications were significantly more likely to have a post-operative medical complication ( p < 0.05). Conclusion: Understanding the unique risk profiles between the various indications and populations of patients undergoing lower extremity free flap reconstruction is critical for providing accurate risk estimations and optimizing post-operative outcomes and monitoring.

Canadian Trends in Free Flap Management for Microsurgical Lower Limb Reconstruction

Introduction: Free tissue transfers have become a mainstay in lower limb salvage, allowing safe and reliable reconstruction after trauma, tumor extirpation, and complex wounds. The optimal perioperative (PO) management of these flaps remains controversial. This study aims to assess the current state of practice among Canadian microsurgeons. Methods: Sixty-four Canadian microsurgeons were approached to complete an online questionnaire regarding their PO management of fasciocutaneous free flaps used for lower limb reconstruction. Trends in dangling timing and duration, use of venous couplers, compressive garments, thromboprophylaxis, and surgeons' satisfaction with their protocol were assessed. Results: Twenty-eight surgeons responded. Fifty-seven percent did not have a specific mobilization protocol. Dangling was mainly initiated on postoperative days 5 to 6 (44%). The most common protocol duration was 5 to 6 days (43%). The concern for prolonged venous pooling was the main reason for delay of dangling (71%). Compressive garments were placed routinely by 12 surgeons (43%) with 20% starting before dangling, 46% with dangling, and 33% after dangling. Venous couplers were routinely used by 24 surgeons (85.7%). Trends in management were influenced by previous training in 53.6% of cases (vs evidence-based medicine 7.1%). Although 89.3% were satisfied with their approach, 92.8% would consider changing practice if higher-level evidence was available. Conclusions: The majority of Canadian microsurgeons initiate dangling early and utilize venous couplers. However, the use of compressive garments is limited. Trends in management are largely based on personal experience. Nearly all surgeons would consider changing their practice if higher-level evidence was available.

Versatility of perforator flaps for lower extremity defect coverage: Technical highlights and single center experience with 87 consecutive cases

BACKGROUND

Lower extremity defects have been and remain one of the greatest challenges in reconstructive surgery. Perforator flaps have been accepted as a valid procedure to cover such a defect. Different techniques have been described and nowadays many options are available. However, there were not studies that comprehensively review the most modern techniques and clinical application of the use of perforator flaps in the lower extremity reconstruction. In the present report, we gathered most of them, presenting an updated and large case series where different pedicled and free perforators flaps were employed in simple and complex scenarios in a large series of cases.

PATIENTS AND METHODS

Eighty-seven patients presenting soft tissue defects of the lower extremities were treated by means of different perforator-based flaps, in either free or pedicled fashion. The flaps were based on different perforator vessels, namely deep lateral circumflex femoral artery, profunda femoris artery, superficial femoral artery, medial sural artery, peroneal artery, posterior tibial artery, anterior tibial artery, and medial plantar artery. Patients' mean age was 61.9 years old (range 21-87 years old), 58 were males and 29 females. The 12 patients received sequential flaps and 9 received double free flaps, for a total sum of 106 flaps. The causes of the defects were trauma in 41 patients and tumors in 46 patients, located throughout the lower limbs. Size of the defect ranged from 3 cm × 4 cm to 25 cm × 9 cm.

RESULTS

The dimensions of the flap skin paddles ranged from 3 cm × 4 cm to 16 cm × 5 cm for the pedicled flaps (42 cases) and from 6 cm × 4 cm to 25 cm × 8 cm for the free ones (45 cases). Mean flap's size was 48 cm² (range 12-80 cm² ) for the pedicle flaps and 104 cm² (range 24-200 cm² ) for free flaps. In two pedicled cases, a distal congestion was encountered, requiring a second surgery. Debulking procedures were performed in 2 patients. All the patients were successfully treated and no flaps were lost. Mean follow-up period was 8.4 months (range 3-12 months). No range of motion impairment was encountered after surgery and all the patients were able to return to habitual life.

CONCLUSIONS

The present case series highlights the reliability and versatility of perforator flaps for lower extremity defect coverage. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap can be potentially successful in the most disparate circumstances.

Prevention and Management of Complications of Tissue Flaps

In this article, we discuss 4 common free flaps performed in reconstructive surgery: the anterolateral thigh flap, the radial forearm flap, the fibula flap, and the transverse rectus abdominis myocutaneous/deep inferior epigastric perforator flap. Donor and recipient complications for each flap type and strategies on how to prevent and manage such complications are discussed.

Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma

The complex lower extremity wound is frequently encountered by orthopedic and plastic surgeons. Innovations in wound care, soft tissue coverage and surgical fixation techniques allow for improved functional outcomes in this patient population with highly morbid injuries. In this review, the principles of reconstruction of complex lower extremity traumatic wounds are outlined. These principles include appropriate initial evaluation of the patient and mangled extremity, as well as appropriate patient selection for limb salvage. The authors emphasize proper planning for reconstruction, timing of reconstruction and the importance of an understanding of the most appropriate reconstructive option. The role of different reconstructive and wound care modalities is discussed, notably negative pressure wound therapy and dermal substitutes. The role of pedicled flaps and microvascular free-tissue transfer are discussed, as are innovations in understanding of perforator anatomy and perforator flap surgery that have broadened the reconstruction surgeon’s armamentarium. Finally, the importance of a multidisciplinary team is highlighted via the principle of the orthoplastic approach to management of complex lower extremity wounds. Upon completion of this review, the reader should have a thorough understanding of the principles of contemporary lower extremity reconstruction.

Modern Principles in the Acute Surgical Management of Open Distal Tibial Fractures

Over the past two decades, management of open distal tibial fractures has evolved such that a staged approach, with external fixation and débridement during the index procedure, followed by definitive fixation and wound closure at a later date, is often considered the standard of care. Although definitive treatment of these complex injuries is often done by a multidisciplinary team of surgeons well versed in periarticular fracture repair and soft-tissue coverage in the distal extremity, the on-call orthopaedic surgeon doing the index procedure must understand the principles and rationale of the staged treatment algorithm to avoid compromising definitive treatment options and ensure the best possible patient outcome. The mechanism of injury, neurovascular status, size and location of soft-tissue injury, fracture pattern, and concomitant injuries in the polytraumatized patient should direct the treatment plan and anticipated outcomes. This review focuses on evaluation and management of these complex injuries with an emphasis on early aggressive débridement, principles of initial fracture fixation, and modern options for soft-tissue coverage, including local and free tissue transfer.

Dangle Protocols in Lower Extremity Reconstruction

INTRODUCTION

Dangling protocols are known to vary by surgeon and center, and their specific regimen is often largely based on single surgeon or institutional experience. A systematic review was conducted to derive evidence-based recommendations for dangling protocols according to patient-specific and flap-specific considerations.

METHODS

A systematic review was performed using PubMed, Embase-OVID and Cochrane-CENTRAL. Study design, patient and flap characteristics, protocol details, dangling-related complications, and flap success rate were recorded. Studies were graded using the Oxford Center for Evidence-Based Medicine Levels of Evidence Scale. Data heterogeneity precluded quantitative analysis.

RESULTS

Eleven articles were included (level of evidence (range):IIb-IV; N (range):8-150; age (range):6-89). Dangling initiation, time, and frequency varied considerably. Flap success rate ranged from 94 to 100%. Active smoking, diabetes, and hypertension are associated with characteristic physiologic changes that require vigilance and potential protocol modification. Early dangling appears to be safe across a variety of free flap locations, sizes, and indications. Axial fasciocutaneous flaps may tolerate more aggressive protocols than muscular flaps. While flaps with single venous anastomosis tolerate dangling, double venous or flow-through anastomoses may provide additional benefit. Major limitations included small sample sizes, uncontrolled study designs, and heterogeneous patient selection, dangling practices, monitoring methods, and outcome measures.

CONCLUSIONS

Significant heterogeneity persists in postoperative dangling protocols after lower extremity microvascular reconstruction. Patient comorbidities and flap characteristics appear to affect tolerance to dangling. We propose two different standardized pathways based on risk factors. Clinical vigilance should be exercised in tailoring lower extremity protocols to patients' individual characteristics and postoperative course.

Free Flaps in Lower Extremity Reconstruction

Free tissue transfer to the lower extremity for limb salvage remains challenging. A comprehensive approach includes patient selection, flap selection, selection of the recipient vessels, flap dissection, flap preparation, microvascular anastomosis, flap inset, immediate postoperative care, intermediate postoperative care, and further follow-up care. Each step in this comprehensive approach has its unique considerations and should be executed equally to ensure an optimal outcome. Once acquired, some clinical experience along with adequate microsurgical skill, good surgical judgment, well instructed and step-by-step intraoperative execution, and a protocol-driven practice, successful free tissue transfer to the lower extremity can be accomplished.

Use of the Adductor Magnus Muscle Free Flap for Lower-Extremity Soft Tissue Coverage: An Alternative to the Gracilis Muscle Flap With Unfavorable Vascular Anatomy

BACKGROUND

The gracilis muscle free flap has proven to be a dependable tool for the reconstructive microsurgeon for coverage of small- to medium-sized lower-extremity soft tissue defects because of its reliable anatomy, ease of elevation, and minimal donor site morbidity. We describe our experience with the adductor magnus muscle free flap which we have utilized in cases when confronted with the rare situation in which the dominant vascular pedicle to the gracilis muscle is insufficient or absent.

METHODS

We conducted a retrospective chart review of a single surgeon's experience (EG Melissinos) over an 18-year period of all patients that underwent adductor magnus muscle free flap coverage for lower-extremity soft tissue injuries.

RESULTS

Twenty-four adductor magnus free flaps in 24 patients were performed over an 18-year period (2000-2018). All of the adductor magnus muscle free flaps were performed with the initial intention of gracilis muscle harvest for lower-extremity soft tissue coverage. The most common wound etiology was motor vehicle collisions (8 patients, 33%). All of the adductor magnus free flaps were used for coverage of lower-extremity wounds in the following anatomic locations: distal third (10 patients, 41.7%), ankle (11 patients, 45.8%) and foot (3 patients, 12.5%). All flaps were successful. There were minimal donor site complications. Limb salvage rate was 100%.

CONCLUSIONS

Use of the adductor magnus muscle free flap is a reasonable alternative to the gracilis muscle in cases when unfavorable gracilis vascular anatomy is encountered intraoperatively. It can be easily and safely harvested within the same donor incision and permits reliable coverage of small- to medium-sized lower-extremity soft tissue defects while avoiding the morbidity of a secondary donor site.

Microsurgery: A 10-Year Experience with Loupe Magnification

Background Microsurgical procedures are still rare in many countries especially in resource-constrained countries. Among reasons for this is the unavailability of operating microscopes that are costly. Operating loupes are considered inferior to the microscope and are most discouraged for many microsurgical procedures. We audit patients operated under loupes for the past 10 years and present our findings.

Patients and Methods This was a prospective audit of patients who underwent microsurgical reconstructive procedures in the plastic surgery unit at Kenyatta National Hospital between January 2009 and December 2019.

Results A total of 352 patients with 360 procedures were done over a 10-year period. The age range for the patients was 5 to 90 years. Free flaps accounted for 78% of the surgical procedures (n = 298) followed by nerve repairs 8.8% (n = 32) and reimplantation surgeries 8.5% (n = 30). The overall success rate for free flaps was 93.3% with reimplantations of 77%.

Conclusion Microsurgical reconstructive procedures as demonstrated in this study can safely be done with loupes. Loupes provide an alternative means of magnification that is cost effective and cheaper. In good hands, good surgical outcomes can be achieved that are comparable to the operating microscopes.

Use of venous couplers in microsurgical lower extremity reconstruction: A systematic review and meta-analysis

BACKGROUND

Free tissue transfer for lower limb reconstruction has become a workhorse procedure for limb-salvage. Compared with other recipient sites, the lower extremity has a higher risk of microvascular complications, in particular with venous anastomosis. The study's objective is to evaluate the evidence, safety, and efficacy of venous coupler use in microsurgical anastomosis in lower limb reconstruction to provide objective appraisal of the surgical techniques.

METHODS

A systematic review (SR) and meta-analysis (MA) were performed analyzing articles from PubMed, Cochrane, Embase, and Web of Science from January 1990, to August 2018. Abstracts and titles were screened and assessed for eligibility by independent reviewers. Following full-text review, articles were included in the SR and MA. Case reports were excluded. Cochrane Collaboration and the Quality of Reporting of Meta-analyses (QUOROM) guidelines were followed.

RESULTS

Out of 15 included studies that met the inclusion criteria for the SR, 9 were included in MA. Patients treated with venous couplers did not experience more surgical complications (risk ratio (RR) 0.79; 95% confidence interval (CI) 0.48-1.33; p = .38), total failure (RR 0.61; 95% CI 0.22-1.70; p = .34), venous compromise (RR 0.72; 95% CI 0.23-2.27; p = .57), arterial compromise (RR 0.85; 95% CI 0.25-2.88; p = .80), partial failure (RR 0.77; 95% CI 0.33-1.77; p = .54), or reoperation (RR 11.79; 95% CI 0.49-286.55; p = .13) in comparison with hand-sewn anastomosis.

CONCLUSIONS

Outcomes of venous couplers in lower limb reconstruction are comparable to those of hand-sewn anastomosis. However, this study was limited by the quality of the available literature. Additional prospective studies should aim to directly compare both techniques and potential further benefits in clinical trials.

Challenges of Setting up a Lower Extremity Reconstruction Practice in a Constrained Environment

BACKGROUND

 Microsurgical lower extremity reconstruction remains challenging, especially when resources are limited such as lack of proper equipment, human resources, administrative support, and located in a remote area far from tertiary care. Nevertheless, reconstructive solutions are required, especially when in urgent trauma situations. In this article, we evaluate ways of overcoming challenges and issues that should be considered in a newly established unit by sharing our initial lower extremity reconstruction experience.

METHODS

 We report a local hospital's initial lower extremity reconstruction experience in February 2017 to January 2018. Through a total of seven patients, we tried to enhance the environment, instruments, nurses' contribution, and perspective of the peers and community in terms of factors related to the surgeon, hardware, environment, supporting faculty, reimbursement, and patients.

RESULTS

 Four patients underwent reconstruction with a freestyle propeller flap and three with an anterolateral thigh flap; in one case, a superficial circumflex iliac artery perforator flap was chosen to salvage partial flap necrosis. Increased experience of the surgeon, new equipment, continuing nurse/patient education, and collaborating with other departments allowed us to choose more challenging flaps and be more meticulous while decreasing the operation time and hospital stay.

CONCLUSION

 To start a lower extremity reconstruction practice in a resource-poor environment, the surgeon needs to evaluate the relevant factors; moreover, he or she should continuously improve them until a working methodology is achieved. Despite all the challenges, the adaptations learned at this center can be applied to other local hospitals around the world to set up a lower extremity reconstruction practice and improve its outcomes.

The Soleus Muscle Flap: An Overview of Its Clinical Applications for Lower Extremity Reconstruction

Lower extremity reconstruction often poses several challenges for the reconstructive surgeon. Because of limited local tissue options, patients who sustain extensive middle to distal third tibia fractures used to be at higher risk of limb loss without adequate soft tissue coverage. The traditional principle of reconstructing middle and distal third leg wounds with free tissue transfer is being challenged by advances in understanding of local muscle flap anatomy and surgical techniques to improve the efficacy of local flaps. In this article, we examine contemporary considerations, developed by the authors, for the appropriate indications of free tissue transfer versus use of local flaps such as the soleus muscle flap. We review the versatility and reliability of the soleus muscle as a local muscle option once the technique is mastered on how to safely and effectively design and execute this flap. We highlight the importance of an algorithmic approach to soft-tissue reconstruction of the lower extremity based on the best surgical option for the patient. This includes factors such as medical history, appropriate surgical candidacy, as well as the size and mechanism of injury to decide the most viable option for lower extremity reconstruction. We show that the medial hemisoleus muscle flap is a reliable local option, both by itself or in conjunction with other local flaps, to reconstruct less extensive wounds in the middle to distal third of the leg. Ultimately, such a local muscle flap must be mastered by the reconstructive surgeon to augment his or her armamentarium to provide a well-rounded reconstructive plan in managing the soft-tissue wound, while minimizing donor-site morbidity and potentially be more cost-effective in nature.

Reoperation of Lower Extremity Microsurgical Reconstruction When Facing Postsplenectomy Thrombocytosis

Patients who sustain high-energy polytrauma are a unique population in that their mechanism of injury may induce multiorgan damage requiring immediate interventions such as splenectomy and bony fixation for mangled extremities. This results in the intersection of certain conditions, such as postsplenectomy thrombocytosis with the need for soft tissue reconstruction, often with free tissue transfer, for limb salvage after severe trauma to the lower extremity. However, there are no treatment guidelines in the management of postsplenectomy thrombocytosis in the setting of a lower extremity free flap reconstruction. We present a patient who had initial free tissue transfer to the lower extremity complicated by delayed microvascular thrombosis at postoperative day 4, during which time his platelet count exceeded more than 1,000,000/mm³. However, a successful second lower extremity free tissue transfer was achieved after platelet-reductive treatment with platelet apheresis during the perioperative period. Our patient went on to heal from his second free flap without further complications. Thus, thrombocytosis in the setting of free tissue transfer requires perioperative intervention to correct this hematologic condition. An innovative utilization of platelet apheresis may ensure the success of free tissue transfer by addressing the thrombocytosis in microsurgical patients after splenectomy.

Thermal Imaging Facilitates Design of a Keystone Perforator Island Flap for a Myxofibrosarcoma Resection Reconstruction: Case Report

Lower extremity defects are challenging to reconstruct. The keystone perforator island flap proves useful in difficult cases. Traditionally, a handheld Doppler is used to confirm perforator vessel(s) within the flap but has disadvantages including low sensitivity/specificity. Surgeons can use thermal imaging to localize “hot spots” on the skin, corresponding to perforators. FLIR ONE (FLIR Systems Inc., Wilsonville, OR) is a portable thermal camera with high concordance with computed tomographic angiography. In this case, when faced with handheld Doppler failure, we used intraoperative thermal imaging to continue planning and raising of a complex lower extremity keystone perforator island flap.