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J Reconstr Microsurg 2018; 34(06): 455-464
DOI: 10.1055/s-0038-1636939
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Free-Flap Lower Extremity Reconstruction: A Cohort Study and Meta-Analysis of Flap Anastomotic Outcomes between Perforator and Nonperforator Flaps

Christopher Tam Song
1   Department of Plastic Surgery, Singapore General Hospital, Singapore, Singapore
,
Keith Koh
1   Department of Plastic Surgery, Singapore General Hospital, Singapore, Singapore
,
Bien-Keem Tan
1   Department of Plastic Surgery, Singapore General Hospital, Singapore, Singapore
,
Terence Goh
1   Department of Plastic Surgery, Singapore General Hospital, Singapore, Singapore
› Author Affiliations
Further Information

Publication History

12 October 2017

18 January 2018

Publication Date:
26 March 2018 (online)

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Abstract

Introduction Free-flap outcomes in lower extremity reconstruction carry the lowest anastomotic success rates compared with other anatomical sites. Despite their advantages over traditional nonperforator flaps, free perforator flaps have only recently become established in this area due to the additional challenges faced. It is therefore crucial to assess the anastomotic outcomes of perforator and nonperforator free flaps.

Methods We performed a single-center retrospective cohort study and combined this with a meta-analysis of the relevant literature. We evaluated three flap anastomotic outcomes: reexploration, operative salvage, and flap failure rates.

Results Between January 2010 and June 2015, our center managed 161 patients who underwent lower extremity free-flap reconstruction, which included 76 perforator flaps and 85 nonperforator flaps. The perforator flaps had higher reexploration rates compared with the nonperforator flaps, but this was not statistically significant (18.4 and 10.6%; p = 0.18). Perforator flaps had a higher flap salvage rate but were not statistically significant (78.6 and 22.2%; p = 0.374). Lastly, although not statistically significant, perforator flaps had a lower rate of complete failure due to anastomotic complications (3.9 and 8.2%; p = 0.336). The meta-analysis included 12 studies (inclusive of the index study) and found no statistical difference in all three outcomes.

Conclusion Our meta-analysis is the first reported study and serves as an indication that free perforator flaps in lower extremity are as reliable as their traditional nonperforator counterparts. This does come with the prerequisite appreciation of the anatomical variations, the delicate handling of these flaps, and a low threshold for reexploration.

Keywords

lower extremity - perforator flap - meta-analysis
 

  • References

  • 1 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
    CrossrefPubMedGoogle Scholar
  • 2 Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989; 42 (06) 645-648
    CrossrefPubMedGoogle Scholar
  • 3 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994; 93 (07) 1503-1504
    CrossrefPubMedGoogle Scholar
  • 4 Review Manager (RevMan). Copenhagen: The Nordic Cochrane Centre. The Cochrane Collaboration. 2014 . Available at: community.cochrane.org/tools/review-production-tools/revman-5/about-revman-5 . Accessed March 5, 2018
    PubMedGoogle Scholar
  • 5 Ohjimi H, Taniguchi Y, Kawano K, Kinoshita K, Manabe T. A comparison of thinning and conventional free-flap transfers to the lower extremity. Plast Reconstr Surg 2000; 105 (02) 558-566
    CrossrefPubMedGoogle Scholar
  • 6 Langstein HN, Chang DW, Miller MJ. , et al. Limb salvage for soft-tissue malignancies of the foot: an evaluation of free-tissue transfer. Plast Reconstr Surg 2002; 109 (01) 152-159
    CrossrefPubMedGoogle Scholar
  • 7 Akoz T, Yildirim S, Akan M, Gideroglu K, Avci G, Cakir B. Can indications for lower limb replantation and revascularization be expanded with simultaneous free-flap transfer for limb salvage?. J Reconstr Microsurg 2004; 20 (08) 621-629
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Yildirim S, Calikapan GT, Akoz T. Reconstructive microsurgery in pediatric population-a series of 25 patients. Microsurgery 2008; 28 (02) 99-107
    CrossrefPubMedGoogle Scholar
  • 9 Ulusal AE, Lin C-H, Lin Y-T, Ulusal BG, Yazar S. The use of free flaps in the management of type IIIB open calcaneal fractures. Plast Reconstr Surg 2008; 121 (06) 2010-2019
    CrossrefPubMedGoogle Scholar
  • 10 Demirtas Y, Kelahmetoglu O, Cifci M, Tayfur V, Demir A, Guneren E. Comparison of free anterolateral thigh flaps and free muscle-musculocutaneous flaps in soft tissue reconstruction of lower extremity. Microsurgery 2010; 30 (01) 24-31
    PubMedGoogle Scholar
  • 11 Tamimy MS, Rashid M, , Ehtesham-ul-Haq, Aman S, Aslam A, Ahmed RS. Has the anterolateral thigh flap replaced the latissimus dorsi flap as the workhorse for lower limb reconstructions?. J Pak Med Assoc 2010; 60 (02) 76-81
    PubMedGoogle Scholar
  • 12 Lee TJ, Noh HJ, Kim EK, Eom JS. Reducing donor site morbidity when reconstructing the nipple using a composite nipple graft. Arch Plast Surg 2012; 39 (04) 384-389
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Hallock GG. A paradigm shift in flap selection protocols for zones of the lower extremity using perforator flaps. J Reconstr Microsurg 2013; 29 (04) 233-240
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Jang YJ, Park MC, Hong YS. , et al. Successful lower extremity salvage with free flap after endovascular angioplasty in peripheral arterial occlusive disease. J Plast Reconstr Aesthet Surg 2014; 67 (08) 1136-1143
    CrossrefPubMedGoogle Scholar
  • 15 Bibbo C, Nelson J, Fischer JP. , et al. Lower extremity limb salvage after trauma: versatility of the anterolateral thigh free flap. J Orthop Trauma 2015; 29 (12) 563-568
    CrossrefPubMedGoogle Scholar
  • 16 Paro J, Chiou G, Sen SK. Comparing muscle and fasciocutaneous free flaps in lower extremity reconstruction--does it matter?. Ann Plast Surg 2016; 76 (Suppl. 03) S213-S215
    CrossrefPubMedGoogle Scholar
  • 17 Soltanian H, Garcia RM, Hollenbeck ST. Current concepts in lower extremity reconstruction. Plast Reconstr Surg 2015; 136 (06) 815e-829e
    CrossrefPubMedGoogle Scholar
  • 18 Melissinos EG, Parks DH. Post-trauma reconstruction with free tissue transfer--analysis of 442 consecutive cases. J Trauma 1989; 29 (08) 1095-1102 , discussion 1102–1103
    CrossrefPubMedGoogle Scholar
  • 19 Percival NJ, Sykes PJ, Earley MJ. Free flap surgery: the Welsh Regional Unit experience. Br J Plast Surg 1989; 42 (04) 435-440
    CrossrefPubMedGoogle Scholar
  • 20 Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma 1989; 29 (08) 1086-1094
    CrossrefPubMedGoogle Scholar
  • 21 Lin CH, Wei FC, Levin LS, Su JI, Yeh WL. The functional outcome of lower-extremity fractures with vascular injury. J Trauma 1997; 43 (03) 480-485
    CrossrefPubMedGoogle Scholar
  • 22 Hallock GG. In an era of perforator flaps, are muscle flaps passé?. Plast Reconstr Surg 2009; 123 (04) 1357-1363
    CrossrefPubMedGoogle Scholar
  • 23 Kim JT, Kim YH, Ghanem AM. Perforator chimerism for the reconstruction of complex defects: a new chimeric free flap classification system. J Plast Reconstr Aesthet Surg 2015; 68 (11) 1556-1567
    CrossrefPubMedGoogle Scholar
  • 24 Philandrianos C, Moullot P, Gay AM. , et al. Soft tissue coverage in distal lower extremity open fractures: comparison of free anterolateral thigh and free latissimus dorsi flaps. J Reconstr Microsurg 2017; (e-pub ahead of print) DOI: 10.1055/s-0037-1607323.
    PubMedGoogle Scholar
  • 25 Kim JH, Kim KN, Yoon CS. Reconstruction of moderate-sized distal limb defects using a superthin superficial circumflex iliac artery perforator flap. J Reconstr Microsurg 2015; 31 (09) 631-635
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Voche P, Merle M. Use of a free gracilis flap for coverage of medium size defects over the ankle and foot. Scand J Plast Reconstr Surg Hand Surg 2002; 36 (02) 91-95
    CrossrefPubMedGoogle Scholar
  • 27 Fox CM, Beem HM, Wiper J, Rozen WM, Wagels M, Leong JC. Muscle versus fasciocutaneous free flaps in heel reconstruction: systematic review and meta-analysis. J Reconstr Microsurg 2015; 31 (01) 59-66
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Chen K-T, Mardini S, Chuang DC-C. , et al. Timing of presentation of the first signs of vascular compromise dictates the salvage outcome of free flap transfers. Plast Reconstr Surg 2007; 120 (01) 187-195
    CrossrefPubMedGoogle Scholar
  • 29 May Jr JW, Chait LA, O'Brien BM, Hurley JV. The no-reflow phenomenon in experimental free flaps. Plast Reconstr Surg 1978; 61 (02) 256-267
    CrossrefPubMedGoogle Scholar
  • 30 Bui DT, Cordeiro PG, Hu Q-Y, Disa JJ, Pusic A, Mehrara BJ. Free flap reexploration: indications, treatment, and outcomes in 1193 free flaps. Plast Reconstr Surg 2007; 119 (07) 2092-2100
    CrossrefPubMedGoogle Scholar
  • 31 Zachara M, Drozdowski P, Wysocki M, Siewiera I, Wójcicki P. Anatomical variability of the anterolateral thigh flap perforators between sexes: a cadaveric study. Eur J Plast Surg 2013; 36 (03) 179-184
    CrossrefPubMedGoogle Scholar
  • 32 Nojima K, Brown SA, Acikel C. , et al. Defining vascular supply and territory of thinned perforator flaps: part I. Anterolateral thigh perforator flap. Plast Reconstr Surg 2005; 116 (01) 182-193
    CrossrefPubMedGoogle Scholar
  • 33 Villafane O, Gahankari D, Webster M. Superficial inferior epigastric vein (SIEV): ‘lifeboat’ for DIEP/TRAM flaps. Br J Plast Surg 1999; 52 (07) 599
    CrossrefPubMedGoogle Scholar
  • 34 Smith RK, Wykes J, Martin DT, Niles N. Perforator variability in the anterolateral thigh free flap: a systematic review. Surg Radiol Anat 2017; 39 (07) 779-789
    CrossrefPubMedGoogle Scholar
  • 35 Goh TLH, Park SW, Cho JY, Choi JW, Hong JP. The search for the ideal thin skin flap: superficial circumflex iliac artery perforator flap--a review of 210 cases. Plast Reconstr Surg 2015; 135 (02) 592-601
    CrossrefPubMedGoogle Scholar
  • 36 Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg 2011; 127 (04) 1447-1459
    Google Scholar
  • 37 Scott JR, Liu D, Said H, Neligan PC, Mathes DW. Computed tomographic angiography in planning abdomen-based microsurgical breast reconstruction: a comparison with color duplex ultrasound. Plast Reconstr Surg 2010; 125 (02) 446-453
    CrossrefPubMedGoogle Scholar
  • 38 Package “pwr.” Basic Functions for Power Analysis. 2017. https://cran.r-project.org/web/packages/pwr/pwr.pdf . Accessed December 6, 2017
    PubMed