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J Reconstr Microsurg 2009; 25(1): 015-019
DOI: 10.1055/s-0028-1090600
© Thieme Medical Publishers

A Recommended Protocol for the Immediate Postoperative Care of Lower Extremity Free-Flap Reconstructions

Christine Rohde1 , Brittny Williams Howell2 , Gregory M. Buncke3 , Geoffrey C. Gurtner4 , L. Scott Levin5 , Lee L.Q Pu6 , Jamie P. Levine7
  • 1Columbia University Medical Center/New York-Presbyterian Hospital, New York
  • 2Department of Surgery, New York University Langone Medical Center, New York, New York
  • 3The Buncke Clinic, California Pacific Medical Center, San Francisco, California
  • 4Division of Plastic Surgery, Stanford University Medical Center, Stanford, California
  • 5Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery, Duke University Medical Center, Durham, North Carolina
  • 6Division of Plastic Surgery, University of California-Davis Medical Center, Sacramento, California
  • 7Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, New York, New York
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Publication History

Publication Date:
31 October 2008 (online)

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ABSTRACT

The success of lower extremity microsurgical reconstructions may be compromised postoperatively secondary to several factors, including thrombosis, infection, bleeding, and edema. To address edema, surgeons may use protocols for gradually dangling and/or wrapping the affected extremity. Such protocols vary widely among surgeons and are typically based on training and/or prior experience. To that end, we distributed surveys to five plastic surgeons who are experienced in microvascular lower extremity reconstruction at five different institutions. The surveys inquired about postoperative management protocols for lower extremity free flaps with regard to positioning, compression, initiation and progression of postoperative mobilization, nonweightbearing and weightbearing ambulation, assessment of flap viability, and flap success rate. These protocols were then evaluated for similarities to create a consensus of postoperative management guidelines. Progressive periods of leg dependency and compression therapy emerged as important elements. Although the consensus protocol developed in this study is considered safe by each participant, we do not intend for these recommendations to serve as a standard of care, nor do we suggest that any one particular protocol leads to improved outcomes. However, these recommendations may serve as a guide for less experienced surgeons or those without a protocol in place.

KEYWORDS

Lower extremity - free flap - dependency - protocol

REFERENCES

  • 1 Parrett B M, Matros E, Pribaz J J, Orgill D. Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures.  Plast Reconstr Surg. 2006;  117 1315-1322
    CrossrefPubMedGoogle Scholar
  • 2 Cierny G, Byrd H S, Jones R E. Primary versus delayed soft tissue coverage for severe open tibial fractures: a comparison of results.  Clin Orthop Relat Res. 1983;  178 54-63
    PubMedGoogle Scholar
  • 3 Greene T L, Beatty M E. Soft tissue coverage for lower extremity trauma.  J Orthop Trauma. 1988;  2 158-173
    PubMedGoogle Scholar
  • 4 Kojima T, Kohono T, Eto T. Muscle flap with simultaneous mesh skin graft for skin defects of the lower leg.  J Trauma. 1979;  19 724-729
    PubMedGoogle Scholar
  • 5 Pollak A N, McCarthy M L, Burgess A R. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group.  J Bone Joint Surg Am. 2000;  82-A 1681-1691
    PubMedGoogle Scholar
  • 6 Kind G M, Dickinson J A, Buncke G M, Buntic R F, Chin B, Buncke Jr H J. Salvage of the severely traumatized lower extremity.  Surg Technol Int. 1997;  6 337-345
    PubMedGoogle Scholar
  • 7 Fiebel R J, Oliva A, Jackson R L, Louie K, Buncke H J. Simultaneous free-tissue transfer and Ilizarov distraction osteosynthesis in lower extremity salvage: case report and review of the literature.  J Trauma. 1994;  37 322-327
    PubMedGoogle Scholar
  • 8 Fiebel R J, Oliva A, Buncke G M, Jackson R L, Buncke H J. Soft-tissue reconstruction in orthopedic surgery. Secondary procedures.  Orthop Clin North Am. 1993;  24 537-548
    PubMedGoogle Scholar
  • 9 Whitney T M, Buncke H J, Alpert B S, Buncke G M, Lineaweaver W C. The serratus anterior free-muscle flap: experience with 100 consecutive cases.  Plast Reconstr Surg. 1990;  86 481-490
    CrossrefPubMedGoogle Scholar
  • 10 Garrett J C, Buncke H J, Brownstein M L. Free groin-flap transfer for skin defects associated with orthopaedic problems of the lower extremity.  J Bone Joint Surg Am. 1978;  60 1055-1058
    PubMedGoogle Scholar
  • 11 Levin L S. Vascularized fibula graft for the traumatically induced long-bone defect.  J Am Acad Orthop Surg. 2006;  14 S175-S176
    PubMedGoogle Scholar
  • 12 Heitmann C, Levin L S. The orthoplastic approach for management of the severely traumatized foot and ankle.  J Trauma. 2003;  54 379-390
    CrossrefPubMedGoogle Scholar
  • 13 Erdmann D, Sundin B M, Yasui K, Wong M S, Levin L S. Microsurgical free flap transfer to amputation sites: indications and results.  Ann Plast Surg. 2002;  48 167-172
    CrossrefPubMedGoogle Scholar
  • 14 Heller L, Levin L S. Lower extremity microsurgical reconstruction.  Plast Reconstr Surg. 2001;  108 1029-1041
    CrossrefPubMedGoogle Scholar
  • 15 Zenn M R, Levin L S. Microvascular reconstruction of the lower extremity.  Semin Surg Oncol. 2000;  19 272-281
    CrossrefPubMedGoogle Scholar
  • 16 Levin L S. The reconstructive ladder. An orthoplastic approach.  Orthop Clin North Am. 1993;  24 393-409
    PubMedGoogle Scholar
  • 17 Rinker B, Valerio I L, Stewart D H, Pu L L, Vasconez H C. Microvascular free flap reconstruction in pediatric lower extremity trauma: a 10-year review.  Plast Reconstr Surg. 2005;  115 1618-1624
    CrossrefPubMedGoogle Scholar
  • 18 Pu L L, Medalie D A, Rosenblum W J, Lawrence S J, Vasconez H C. Free tissue transfer to a difficult wound of the lower extremity.  Ann Plast Surg. 2004;  53 222-228
    CrossrefPubMedGoogle Scholar
  • 19 Marek C A, Pu L L. Refinements of free tissue transfer for optimal outcome in lower extremity reconstruction.  Ann Plast Surg. 2004;  52 270-275
    CrossrefPubMedGoogle Scholar
  • 20 Pu L L, Medalie D A, Lawrence S J, Vasconez H C. Reconstruction of through-and-through gunshot wounds to the feet with free gracilis muscle flaps.  Ann Plast Surg. 2003;  50 286-291
    CrossrefPubMedGoogle Scholar
  • 21 Dublin B A, Karp N S, Kasabian A K, Kolker A R, Shah M H. Selective use of preoperative lower extremity arteriography in free flap reconstruction.  Ann Plast Surg. 1997;  38 404-407
    CrossrefPubMedGoogle Scholar
  • 22 Kolker A R, Kasabian A K, Karp N S, Gottlieb J J. Fate of free flap microanastomosis distal to the zone of injury in lower extremity trauma.  Plast Reconstr Surg. 1997;  99 1068-1073
    CrossrefPubMedGoogle Scholar
  • 23 Benacquista T, Kasabian A K, Karp N S. The fate of lower extremities with failed free flaps.  Plast Reconstr Surg. 1996;  98 834-840
    CrossrefPubMedGoogle Scholar
  • 24 Choe E I, Kasabian A K, Kolker A R et al.. Thrombocytosis after major lower extremity trauma: mechanism and possible role in free flap failure.  Ann Plast Surg. 1996;  36 489-494
    PubMedGoogle Scholar
  • 25 Kasabian A K, Glat P M, Eidelman Y et al.. Salvage of traumatic below-knee amputation stumps utilizing the filet of foot free flap: critical evaluation of six cases.  Plast Reconstr Surg. 1995;  96 1145-1153
    PubMedGoogle Scholar
  • 26 Denk M J, Longaker M T, Basner A L, Glatt P M, Karp N S, Kasabian A K. Microsurgical reconstruction of the lower extremity using the 3M microvascular coupling device in venous anastomoses.  Ann Plast Surg. 1995;  35 601-616
    CrossrefPubMedGoogle Scholar
  • 27 Daniel R K, Kerrigan C L. Principles and physiology of skin flap surgery. In McCarthy JG Plastic Surgery. Philadelphia, PA; WB Saunders 1990: 275-328
    Google Scholar
  • 28 Palmer B, Jurell G, Norberg K A. The blood flow in experimental skin flaps in rats studied by means of the 133 xenon clearance method.  Scand J Plast Reconstr Surg. 1972;  6 6-12
    CrossrefPubMedGoogle Scholar
  • 29 Nathanson S E, Jackson R T. Blood flow measurements in skin flaps.  Arch Otolaryngol. 1975;  101 354-357
    CrossrefPubMedGoogle Scholar
  • 30 Kerrigan C L, Daniel R K. Monitoring acute skin-flap failure.  Plast Reconstr Surg. 1983;  71 519-524
    CrossrefPubMedGoogle Scholar
  • 31 Kerrigan C L, Daniel R K. Skin flap research: a candid view.  Ann Plast Surg. 1984;  13 383-387
    CrossrefPubMedGoogle Scholar
  • 32 Serafin D, Shearin J C, Georgiade N G. The vascularization of free flaps: a clinical and experimental correlation.  Plast Reconstr Surg. 1977;  60 233-241
    CrossrefPubMedGoogle Scholar
  • 33 Nakajima T. How soon do venous drainage channels develop at the periphery of a free flap? A study in rats.  Br J Plast Surg. 1978;  31 300-308
    CrossrefPubMedGoogle Scholar
  • 34 Tsur H, Daniller A, Strauch B. Neovascularization of skin flaps: route and timing.  Plast Reconstr Surg. 1980;  66 85-90
    PubMedGoogle Scholar
  • 35 Young C M. The revascularization of pedicle skin flaps in pigs: a functional and morphological study.  Plast Reconstr Surg. 1982;  70 455-464
    PubMedGoogle Scholar
  • 36 Black M J, Chait L, O'Brien B M, Sykes P J, Sharzer L A. How soon may the axial vessels of a surviving free flap be safely ligated: a study in pigs.  Br J Plast Surg. 1978;  31 295-299
    CrossrefPubMedGoogle Scholar
  • 37 Rothaus K O, Acland R D. Free flap neo-vascularisation: case report.  Br J Plast Surg. 1983;  36 348-349
    CrossrefPubMedGoogle Scholar
  • 38 Rath T, Piza H, Opitz A. Survival of a free musculocutaneous flap after early loss of arterial blood supply.  Br J Plast Surg. 1986;  39 530-532
    CrossrefPubMedGoogle Scholar
  • 39 Fujino T. Contribution of the axial and perforator vasculature to circulation in flaps.  Plast Reconstr Surg. 1967;  39 125-137
    CrossrefPubMedGoogle Scholar
  • 40 Myers M B, Cherry G. Design of skin flaps to study vascular insufficiency.  J Surg Res. 1967;  7 399-405
    CrossrefPubMedGoogle Scholar
  • 41 Fukui A, Tamai S, Williams H B. The importance of venous drainage in rat flaps: an experimental study.  J Reconstr Microsurg. 1989;  5 19-30
    Article in Thieme ConnectPubMedGoogle Scholar
  • 42 Chow S P, Chen D Z, Gu Y D. The significance of venous drainage in free-flap transfer.  Plast Reconstr Surg. 1993;  91 713-715
    CrossrefPubMedGoogle Scholar
  • 43 Miles D A, Crosby N L, Clapson J B. The role of the venous system in the abdominal flap of the rat.  Plast Reconstr Surg. 1997;  99 2030-2033
    CrossrefPubMedGoogle Scholar
  • 44 Isenberg J S, Siegal A, Sherman R. Quantitative evaluation of the effects of gravity and dependency on microvascular tissue transfer to the lower limb, with clinical applications.  J Reconstr Microsurg. 1997;  13 25-29
    Article in Thieme ConnectPubMedGoogle Scholar

Jamie P LevineM.D. 

530 First Avenue, Suite 8V, NYU Plastic Surgery Associates

NYU Medical Center, New York, NY 10016

Email: jamie.levine@nyumc.org