Modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure for complex lower extremity reconstruction

Abstract

Background Complex lower limb reconstruction due to severe trauma remains a challenge for reconstructive surgeons. Here, we introduce a modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure and evaluate its clinical efficacy. Methods Between January 2013 and December 2019, 22 patients (range 10 to 64 years old) with unilateral lower limb injury underwent modified donor blood flow-preserved cross-leg anterolateral thigh flap procedures. Among them, 16 cases were traffic accidents, 5 cases were persistent ulcers, and 1 case was a degloving injury. The arterial pedicle of the flap was prepared in a Y-shaped fashion and microanastomosed to the posterior tibial artery of intact leg in a flow-through style. A split-thickness skin graft was applied to wrap the vascular pedicle after anastomosis. The flap was designed in a single or bilobed fashion according to the shape of the tissue defect. The operation time, the intraoperative blood loss and the length of hospital stays were recorded. The vascular pedicle was divided 4 weeks after anastomosis. Doppler ultrasound was performed to evaluate the blood flow of the donor posterior tibial artery during postoperative follow-up. Results All 22 flaps survived. The tissue defects ranged from 12 × 6 to 21 × 18 cm2. The flap sizes ranged from 14 × 7.5 to 24 × 21 cm2. The average operation time, intraoperative blood loss and length of hospital stays were 6.73 ± 1.49 h, 280.95 ± 59.25 ml and 30.55 ± 2.52 days, respectively. Eighteen flaps were designed in a single fashion, while four were in bilobed fashion. Twenty patients underwent fasciocutaneous flap transplantations, while two underwent musculocutaneous flap transplantations. Two cases developed local lysis of the flap which healed after further debridement. Direct suture of the incision after flap harvest was performed in 16 cases, while additional full-thickness skin grafting was performed in the remaining 6 cases. Further bone transport procedures were performed in 15 patients who had severe tibia bone defects. The blood flow of donor posterior tibial artery was confirmed in all patients during follow-ups. All patients recovered flap sensation at the final follow-up. The postoperative follow-ups ranged from 18 to 84 months, and no long-term complications were observed. Conclusions The modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure is an ideal method to repair severe lower limb trauma with tibial artery occlusion which avoids sacrificing the major artery of the uninjured lower limb.

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

“…In addition, it is difficult to prepare a segment of Y-shaped or T-shaped arterial bifurcation during the harvest of free latissimus dorsi flap. 14,35 Yu et al suggested an alternative option to preserve integrity of the recipient vessel which is an end-to-side anastomoses to the contralateral limb in order to maintain continuity of the distal blood flow, although they performed the microvascular anastomoses of their cross-leg bridge free flaps series in an end-to-end fashion. 11 Several previous studies have reported the use of end-to-side anastomosis to recipient vessels in the same injured leg to preserve the leg vascular flow and reported no significant difference in the rate of flap complications between the outcome of end-toend and end-to-side anastomoses in free flap reconstruction of lower limb defects.…”

“…In addition, it is difficult to prepare a segment of Y-shaped or T-shaped arterial bifurcation during the harvest of free latissimus dorsi flap. 14 35 …”

“…is difficult to prepare a segment of Y-shaped or T-shaped arterial bifurcation during the harvest of free latissimus dorsi flap. [14,35] Yu et al suggested an alternative option to preserve integrity of the recipient vessel which is an end-to-side anastomoses to the contralateral limb in order to maintain continuity of the distal blood flow, although they performed the microvascular anastomoses of their cross-leg bridge free flaps series in an end-to-end fashion. [11].…”

The Autonomization Principle in Vascularized Flaps: An Alternative Strategy for Composite Tissue Scaffold In Vivo Revascularization

“…Regarding lower limb reconstructions, the conventional autonomization delay is considered to be slightly longer. Even if some authors have described earlier time points [71], the cross-leg flap is mostly divided after at least 4 weeks [15][16][17], even in the most recent case series [18,[72][73][74][75]. Modern technologies have brought interesting applications to the study of flap autonomization.…”