Download PDF
J Reconstr Microsurg 2015; 31(06): 420-425
DOI: 10.1055/s-0035-1548549
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Overcoming the Obstacles of the Ilizarov Device in Extremity Reconstruction: Usefulness of the Perforator as the Recipient Vessel

Kyu Nam Kim
1   Department of Plastic and Reconstructive Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
,
Joon Pio Hong
2   Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
,
Sung Woo Park
2   Department of Plastic and Reconstructive Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
,
Sang Woo Kim
3   Department of Orthopaedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
,
Chi Sun Yoon
1   Department of Plastic and Reconstructive Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
› Author Affiliations
Further Information

Publication History

26 November 2014

01 February 2015

Publication Date:
31 March 2015 (online)

Also available at
    Permissions and Reprints

Abstract

Background When patients using the Ilizarov device need a free-flap procedure for their thigh and leg, it is difficult to isolate the major vessels as the recipient vessel due to the limited working space around the Ilizarov rings and pins. The usefulness of a perforator as the recipient vessel to allow minimally invasive surgery was investigated in this study.

Methods Between October 2011 and December 2013, 77 patients using the Ilizarov device needed free flap reconstruction using an anterolateral thigh perforator flap or superficial circumflex iliac artery perforator flap. The perforator was used as a recipient vessel in 50 cases, with which end-to-end anastomosis was performed using a perforator-to-perforator approach, and major vessels were used as a recipient vessel in 27 cases (n = 20, anterior tibial vessel; n = 7, posterior vessel).

Results When the perforator was used as the recipient vessel, total loss developed in one case and marginal necrosis in four cases. When the major vessel was used as the recipient vessel, whole necrosis developed in one case and marginal necrosis in two cases. The procedure increased the freedom of hand movement, decreased the recipient vessel dissection time, and reduced the recipient dissection scar.

Conclusions The use of perforators as recipients overcomes the obstacles associated with the Ilizarov device and allows convenient and rapid reconstruction, with similar success as microsurgery using major vessels. Further studies are needed to address the limitations of this approach, which include perfusion physiology and the viable limit of the flap dimension.

Keywords

Ilizarov device - supermicrosurgery - perforator-to-perforator anastomosis
 

  • References

  • 1 Park S, Han SH, Lee TJ. Algorithm for recipient vessel selection in free tissue transfer to the lower extremity. Plast Reconstr Surg 1999; 103 (7) 1937-1948
    CrossrefPubMedGoogle Scholar
  • 2 Boopalan PR, Jepegnanam TS. Reverse sural flap cover within a ring fixator. Acta Orthop Belg 2010; 76 (5) 684-688
    PubMedGoogle Scholar
  • 3 Yazar S, Lin CH. Selection of recipient vessel in traumatic lower extremity. J Reconstr Microsurg 2012; 28 (3) 199-204
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 Acland RD. Refinements in lower extremity free flap surgery. Clin Plast Surg 1990; 17 (4) 733-744
    CrossrefPubMedGoogle Scholar
  • 5 Chen HC, Chuang CC, Chen S, Hsu WM, Wei FC. Selection of recipient vessels for free flaps to the distal leg and foot following trauma. Microsurgery 1994; 15 (5) 358-363
    CrossrefPubMedGoogle Scholar
  • 6 Samaha FJ, Oliva A, Buncke GM, Buncke HJ, Siko PP. A clinical study of end-to-end versus end-to-side techniques for microvascular anastomosis. Plast Reconstr Surg 1997; 99 (4) 1109-1111
    CrossrefPubMedGoogle Scholar
  • 7 Fischer JP, Wink JD, Nelson JA , et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013; 29 (6) 407-416
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Wink JD, Nelson JA, Fischer JP, Cleveland EC, Kovach III SJ. Free tissue transfer for complex reconstruction of the lower extremity: experience of a young microsurgeon. J Reconstr Microsurg 2014; 30 (5) 349-358
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Hallock GG. A paradigm shift in flap selection protocols for zones of the lower extremity using perforator flaps. J Reconstr Microsurg 2013; 29 (4) 233-240
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Zhong C, Tang NX, Zheng CF, Xu YW, Wang TD. Experimental study on microvascular anastomosis using a dissolvable stent support in the lumen. Microsurgery 1991; 12 (2) 67-71
    CrossrefPubMedGoogle Scholar
  • 11 Yamamoto N, Nakai H, Satoh Y, Oshima Y. Clinical application of a nonpenetrating microvascular stapling device for vascularized free tissue transfer. Ann Plast Surg 1999; 42 (1) 49-55
    CrossrefPubMedGoogle Scholar
  • 12 Karamürsel S, Kayikçioğlu A, Safak T, Keçik A, Sürücü S. A new technique for microvascular anastomosis: external metallic circle. Plast Reconstr Surg 1999; 104 (4) 1059-1065
    CrossrefPubMedGoogle Scholar
  • 13 Verhelle NA, Heymans O. How to deal with difficult microsurgical end-to-side anastomoses. Microsurgery 2005; 25 (3) 203-208
    CrossrefPubMedGoogle Scholar
  • 14 Kim JT, Kim CY, Kim YH. T-anastomosis in microsurgical free flap reconstruction: an overview of clinical applications. J Plast Reconstr Aesthet Surg 2008; 61 (10) 1157-1163
    CrossrefPubMedGoogle Scholar
  • 15 Hong JP, Koshima I. Using perforators as recipient vessels (supermicrosurgery) for free flap reconstruction of the knee region. Ann Plast Surg 2010; 64 (3) 291-293
    CrossrefPubMedGoogle Scholar
  • 16 Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution. Plast Reconstr Surg 2009; 123 (1) 230-235
    CrossrefPubMedGoogle Scholar
  • 17 Kim CY, Naidu S, Kim YH. Supermicrosurgery in peroneal and soleus perforator-based free flap coverage of foot defects caused by occlusive vascular diseases. Plast Reconstr Surg 2010; 126 (2) 499-507
    CrossrefPubMedGoogle Scholar
  • 18 Hong JP, Choi DH, Suh H , et al. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014; 30 (7) 491-496
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 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 (4) 401-405
    CrossrefPubMedGoogle Scholar
  • 20 Fiebel RJ, Oliva A, Jackson RL, Louie K, Buncke HJ. Simultaneous free-tissue transfer and Ilizarov distraction osteosynthesis in lower extremity salvage: case report and review of the literature. J Trauma 1994; 37 (2) 322-327
    CrossrefPubMedGoogle Scholar
  • 21 McKee MD, Yoo DJ, Zdero R , et al. Combined single-stage osseous and soft tissue reconstruction of the tibia with the Ilizarov method and tissue transfer. J Orthop Trauma 2008; 22 (3) 183-189
    CrossrefPubMedGoogle Scholar
  • 22 Park S, Lee TJ. Strategic considerations on the configuration of free flaps and their vascular pedicles combined with Ilizarov distraction in the lower extremity. Plast Reconstr Surg 2000; 105 (5) 1680-1686
    CrossrefPubMedGoogle Scholar
  • 23 Segev E, Wientroub S, Kollender Y, Meller I, Amir A, Gur E. A combined use of a free vascularised flap and an external fixator for reconstruction of lower extremity defects in children. J Orthop Surg (Hong Kong) 2007; 15 (2) 207-210
    PubMedGoogle Scholar
  • 24 Lowenberg DW, Feibel RJ, Louie KW, Eshima I. Combined muscle flap and Ilizarov reconstruction for bone and soft tissue defects. Clin Orthop Relat Res 1996; (332) 37-51
    PubMedGoogle Scholar
  • 25 Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S, Fujitsu M. Minimal invasive lymphaticovenular anastomosis under local anesthesia for leg lymphedema: is it effective for stage III and IV?. Ann Plast Surg 2004; 53 (3) 261-266
    CrossrefPubMedGoogle Scholar
  • 26 Koshima I, Inagawa K, Yamamoto M, Moriguchi T. New microsurgical breast reconstruction using free paraumbilical perforator adiposal flaps. Plast Reconstr Surg 2000; 106 (1) 61-65
    CrossrefPubMedGoogle Scholar