Reconstruction of the Lower Extremity with Cross-Leg Free Flaps

Abstract

Background?The absence of suitable adjacent recipient vessels for microvascular anastomosis due to trauma poses a major challenge to the reconstructive surgeon. The anterior and posterior tibial vessels of the contralateral leg are the two other alternatives for use as recipient vessels for microvascular anastomosis. This method is known as the cross-leg free flap. Methods?Twenty-seven patients (20 males, 7 females) underwent cross-leg free flap operations due to absence of a suitable adjacent recipient vessel between 2007 and 2015. The mean soft tissue defect dimension was 12???11 cm (smallest: 6???7 cm; largest: 20 ?14 cm). Gustilo type 3B tibia fractures were present in 19 patients, but no fractures were present in the other 8. Six different flaps were used: 14 anterolateral thigh flaps, 6 latissimus dorsi flaps, 3 gracilis muscle flaps, 2 vastus lateralis musculocutaneous flaps, 1 tensor fascia latae flap, and 1 deep inferior epigastric perforator flap. Results?Two anterolateral thigh flaps failed, while the rest of the flaps survived completely. There were no donor-site complications. Conclusion?We think that the cross-leg free flap method can be safely and successfully used with all flap types in complex lower extremity injuries in which the adjacent recipient vessel option is unavailable.

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

“…The continuous improvement of the outcomes of microsurgical interventions has made free flap reconstruction a routine option in lower extremity reconstructive surgery [19]. Successful free flap reconstruction of leg defects requires optimal flap choice, in addition to selecting appropriate recipient vessels in the leg [7]. However, the lack of recipient vessels or the presence of single artery in the injured leg makes the free flap transfer a challenging and unsafe procedure.…”

“…2 Cross-leg free flaps allow the transfer of the needed tissues including skin and muscle with or without bone using microvascular anastomoses performed away from the zone of injury to reconstruct challenging tissue defects with healthy vascularized tissue. 4,7 Since 1979, several studies have been published reporting successful reconstruction of leg defects using cross-leg free tissue transfer with end-to-end anastomosis. Some studies described using large muscle flaps such as latissimus dorsi which helped in the successful salvage of complicated leg defects 6,8,10 and in treatment of osteomyelitis.…”

“…11 Ozkan applied the same principle in 27 patients using different skin and muscle flaps including anterolateral thigh, latissimus dorsi muscle, gracilis muscle, vastus lateralis musculocutaneous, tensor fascia latae, and deep inferior epigastric perforator flaps, with 93% success rate. 7 Latissimus dorsi flap has many advantages as a cross-leg free flap in the reconstruction of complex leg defects as it can provide a sizable flap with a long pedicle and good vessel caliber. 31 Its large muscle component allows durable closure of complex wide defects.…”

“…Yu et al published a large series of 85 patients who underwent cross-leg free flap reconstruction utilizing a variety of flaps including latissimus dorsi myocutaneous, free fibula, free fibular osteocutaneous, and free iliac osteocutaneous flaps and showed an overall success rate of 95% [11]. Ozkan applied the same principle in 27 patients using different skin and muscle flaps including anterolateral thigh, latissimus dorsi muscle, gracilis muscle, vastus lateralis musculocutaneous, tensor fascia latae, and deep inferior epigastric perforator flaps, with 93% success rate [7].…”

“…This temporary vascular anastomosis supports the flap until it forms sufficient vascular connections with its edges and bed in the injured leg, then separation is performed. 4 A number of studies have reported successful reconstruction of leg defects with cross-leg free tissue transfer, utilizing muscle/musculocutaneous flaps such as latissimus dorsi, rectus abdominis, gracilis, and vastus lateralis muscles [5][6][7][8][9][10][11] ; cutaneous flaps such as anterolateral thigh and deep inferior epigastric perforator flaps 7 ; or osteocutaneous flaps such as deep circumflex iliac artery (DCIA) and fibular flaps. 7,11,12 Most of these previous studies used end-to-end anastomoses to the recipient vessel in the contralateral uninjured leg.…”