RSS-Feed abonnieren
DOI: 10.1055/s-0032-1328919
A Paradigm Shift in Flap Selection Protocols for Zones of the Lower Extremity using Perforator Flaps
Publikationsverlauf
27. Mai 2012
09. Juli 2012
Publikationsdatum:
05. März 2013 (online)
![](https://www.thieme-connect.de/media/jrm/201304/lookinside/thumbnails/10.1055-s-0032-1328919-1.jpg)
Abstract
Background Significant lower limb wounds often require soft tissue coverage using vascularized flaps. Traditionally, local muscles have been used for the proximal lower extremity and free flaps for the distal leg and foot, but perforator flaps over the past decade have been shown to be a reliable alternative.
Methods The evolution of our lower limb flap selection for the period 1996 to 2000 was retrospectively compared with our current approach using perforator flaps. Flap selection was never random, but based according to wound location, severity, and flap availability.
Results In the preperforator flap era, 101 of 122 (82.8%) flaps were muscle flaps. Over the last 5 years, this relative usage decreased to 36.4%, whereas perforator flaps were chosen almost half the time (49.6%). Local flaps still predominated as the choice for the proximal lower limb, and free flaps more distally, with perforator free flaps chosen twice as often as muscle flaps. Major complications occurred most commonly in the more distal lower extremity and were related to microsurgical catastrophes and not flap subtype.
Conclusions Perforator flaps can be another soft tissue choice for all zones of the lower extremity, recognizing that function preservation is their major asset as no muscle need be included. Peninsular, propeller, or advancement perforator flaps proved to be valuable local nonmicrosurgical flap alternatives.
Notes
This paper was presented in part at The Tenth Annual John Knowles Swinburne Memorial Lecture, Nassau University Medical Center, East Meadow, New York, May 8, 2010; Symposium in Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota, June 26, 2010 and June 2, 2012; 4th Annual Quality Medical Publications Reconstructive Surgery Symposium, St. Louis, Missouri, November 21, 2010; 6th Conference of the World Society for Reconstructive Microsurgery, Helsinki, Finland, June 30, 2011.
-
References
- 1 Hallock GG. Utility of both muscle and fascia flaps in severe lower extremity trauma. J Trauma 2000; 48: 913-917
- 2 Aldea PA, Shaw WW. The evolution of the surgical management of severe lower extremity trauma. Clin Plast Surg 1986; 13: 549-569
- 3 Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR, Poka A, Weiland AJ. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg 1987; 80: 1-14
- 4 Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg 1992; 89: 478-487 , discussion 488–489
- 5 Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of mangled lower extremities. J Trauma 1993; 34: 99-104
- 6 Doucet JJ, Galarneau MR, Potenza BM , et al. Combat versus civilian open tibia fractures: the effect of blast mechanism on limb salvage. J Trauma 2011; 70: 1241-1247
- 7 Fern KT, Smith JT, Zee B, Lee A, Borschneck D, Pichora DR. Trauma patients with multiple extremity injuries: resource utilization and long-term outcome in relation to injury severity scores. J Trauma 1998; 45: 489-494
- 8 Dagum AB, Best AK, Schemitsch EH, Mahoney JL, Mahomed MN, Blight KR. Salvage after severe lower-extremity trauma: are the outcomes worth the means?. Plast Reconstr Surg 1999; 103: 1212-1220
- 9 Medina ND, Kovach III SJ, Levin LS. An evidence-based approach to lower extremity acute trauma. Plast Reconstr Surg 2011; 127: 926-931
- 10 Reddy V, Stevenson TR. MOC-PS(SM) CME article: lower extremity reconstruction. Plast Reconstr Surg 2008; 121 (4, Suppl) 1-7
- 11 Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg 2010; 125: 924-934
- 12 DeFranzo AJ, Argenta LC, Marks MW , et al. The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone. Plast Reconstr Surg 2001; 108: 1184-1191
- 13 Hallock GG, Morris SF. Skin grafts and local flaps. Plast Reconstr Surg 2011; 127: 5e-22e
- 14 Lee LF, Porch JV, Spenler W, Garner WL. Integra in lower extremity reconstruction after burn injury. Plast Reconstr Surg 2008; 121: 1256-1262
- 15 Menn ZK, Lee E, Klebuc MJ. Acellular dermal matrix and negative pressure wound therapy: a tissue-engineered alternative to free tissue transfer in the compromised host. J Reconstr Microsurg 2012; 28: 139-144
- 16 Grotting JC, Vasconez LO. Regional blood supply and the selection of flaps for reconstruction. Clin Plast Surg 1986; 13: 581-593
- 17 Pontén B. The fasciocutaneous flap: its use in soft tissue defects of the lower leg. Br J Plast Surg 1981; 34: 215-220
- 18 Hallock GG. Local fasciocutaneous flaps for cutaneous coverage of lower extremity wounds. J Trauma 1989; 29: 1240-1244
- 19 Nakajima H, Fujino T, Adachi S. A new concept of vascular supply to the skin and classification of skin flaps according to their vascularization. Ann Plast Surg 1986; 16: 1-19
- 20 Hallock GG. Direct and indirect perforator flaps: the history and the controversy. Plast Reconstr Surg 2003; 111: 855-865 , quiz 866
- 21 Lee BT, Lin SJ, Bar-Meir ED, Borud LJ, Upton J. Pedicled perforator flaps: a new principle in reconstructive surgery. Plast Reconstr Surg 2010; 125: 201-208
- 22 Schaverien M, Saint-Cyr M. Perforators of the lower leg: analysis of perforator locations and clinical application for pedicled perforator flaps. Plast Reconstr Surg 2008; 122: 161-170
- 23 Lykoudis EG, Koutsouris M, Lykissas MG. Vascular anatomy of the integument of the lateral lower leg: an anatomical study focused on cutaneous perforators and their clinical importance. Plast Reconstr Surg 2011; 128: 188-198
- 24 Lu TC, Lin CH, Lin CH, Lin YT, Chen RF, Wei FC. Versatility of the pedicled peroneal artery perforator flaps for soft-tissue coverage of the lower leg and foot defects. J Plast Reconstr Aesthet Surg 2011; 64: 386-393
- 25 Neale HW, Stern PJ, Kreilein JG, Gregory RO, Webster KL. Complications of muscle-flap transposition for traumatic defects of the leg. Plast Reconstr Surg 1983; 72: 512-517
- 26 Hallock GG. Further clarification of the nomenclature for compound flaps. Plast Reconstr Surg 2006; 117: 151e-160e
- 27 Higueras Suñé MC, López Ojeda A, Narváez García JA , et al. Use of angioscanning in the surgical planning of perforator flaps in the lower extremities. J Plast Reconstr Aesthet Surg 2011; 64: 1207-1213
- 28 Thiessen FE, Andrades P, Blondeel PN , et al. Flap surgery for pressure sores: should the underlying muscle be transferred or not?. J Plast Reconstr Aesthet Surg 2011; 64: 84-90
- 29 Hallock GG. In an era of perforator flaps, are muscle flaps passé?. Plast Reconstr Surg 2009; 123: 1357-1363
- 30 Pignatti M, Ogawa R, Hallock GG , et al. The “Tokyo” consensus on propeller flaps. Plast Reconstr Surg 2011; 127: 716-722
- 31 El-Sabbagh AH. Skin perforator flaps: an algorithm for leg reconstruction. J Reconstr Microsurg 2011; 27: 511-523
- 32 Hallock GG. Sequential use of a true perforator flap and its corresponding muscle flap. Ann Plast Surg 2003; 51: 617-620 , discussion 621–622
- 33 Baumeister SP, Spierer R, Erdmann D, Sweis R, Levin LS, Germann GK. A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group. Plast Reconstr Surg 2003; 112: 129-140 , discussion 141–142
- 34 Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S, Fujino T. Accompanying arteries of the cutaneous veins and cutaneous nerves in the extremities: anatomical study and a concept of the venoadipofascial and/or neuroadipofascial pedicled fasciocutaneous flap. Plast Reconstr Surg 1998; 102: 779-791
- 35 Ullmann Y, Fodor L, Ramon Y, Soudry M, Lerner A. The revised “reconstructive ladder” and its applications for high-energy injuries to the extremities. Ann Plast Surg 2006; 56: 401-405
- 36 Hallock GG. Lower extremity muscle perforator flaps for lower extremity reconstruction. Plast Reconstr Surg 2004; 114: 1123-1130