J Reconstr Microsurg 2021; 37(01): 083-088
DOI: 10.1055/s-0040-1708835
Original Article

Importance of Vascularity and Selecting the Recipient Vessels of Lower Extremity Reconstruction

Joon Pio Hong
1   Department of Plastic Surgery, ASAN Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
,
Changsik John Park
1   Department of Plastic Surgery, ASAN Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
,
Hyunsuk Peter Suh
1   Department of Plastic Surgery, ASAN Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
› Author Affiliations

Abstract

Background Successful lower extremity reconstruction using free flaps begins by identifying a good recipient vessel and understanding the surrounding environment of the defect.

Methods One should consider multiple factors when selecting the recipient vessel such as the status of the axial arteries, trying to preserve flow as much as possible, extent and severity of the defect, and ultimately what type of anastomosis will be ideal.

Results Multiple factors of importance are reviewed and show the relevance in decision making and provide an algorithm.

Conclusion In addition to the multiple factors to be considered, the ultimate decision should be made on the table during surgery when the actual artery or vein is exposed and shows signs of good pulsation and flow.



Publication History

Received: 13 December 2019

Accepted: 02 February 2020

Article published online:
06 April 2020

© 2020. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Bosse MJ, MacKenzie EJ, Kellam JF. et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002; 347 (24) 1924-1931
  • 2 Chung KC, Saddawi-Konefka D, Haase SC, Kaul G. A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures. Plast Reconstr Surg 2009; 124 (06) 1965-1973
  • 3 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994; 93 (07) 1503-1504
  • 4 Xiong L, Gazyakan E, Kremer T. et al. Free flaps for reconstruction of soft tissue defects in lower extremity: a meta-analysis on microsurgical outcome and safety. Microsurgery 2016; 36 (06) 511-524
  • 5 Serafin D, Voci VE. Reconstruction of the lower extremity. Microsurgical composite tissue transplantation. Clin Plast Surg 1983; 10 (01) 55-72
  • 6 Abdelfattah U, Power HA, Song S, Min K, Suh HP, Hong JP. Algorithm for free perforator flap selection in lower extremity reconstruction based on 563 cases. Plast Reconstr Surg 2019; 144 (05) 1202-1213
  • 7 Lutz BS, Ng SH, Cabailo R, Lin CH, Wei FC. Value of routine angiography before traumatic lower-limb reconstruction with microvascular free tissue transplantation. J Trauma 1998; 44 (04) 682-686
  • 8 Reddy V, Stevenson TR. MOC-PS(SM) CME article: lower extremity reconstruction. Plast Reconstr Surg 2008; 121 (04) 1-7
  • 9 Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg 2001; 108 (04) 1029-1041 , quiz 1042
  • 10 Dublin BA, Karp NS, Kasabian AK, Kolker AR, Shah MH. Selective use of preoperative lower extremity arteriography in free flap reconstruction. Ann Plast Surg 1997; 38 (04) 404-407
  • 11 Duymaz A, Karabekmez FE, Vrtiska TJ, Mardini S, Moran SL. Free tissue transfer for lower extremity reconstruction: a study of the role of computed angiography in the planning of free tissue transfer in the posttraumatic setting. Plast Reconstr Surg 2009; 124 (02) 523-529
  • 12 Haddock NT, Weichman KE, Reformat DD, Kligman BE, Levine JP, Saadeh PB. Lower extremity arterial injury patterns and reconstructive outcomes in patients with severe lower extremity trauma: a 26-year review. J Am Coll Surg 2010; 210 (01) 66-72
  • 13 Wang Z, Yi X, He J. et al. Catheter-based computed tomography angiography in anterolateral thigh perforator mapping of Chinese patients. J Reconstr Microsurg 2019; 35 (03) 221-228
  • 14 Mun GH, Lee SJ, Jeon BJ. Perforator topography of the thoracodorsal artery perforator flap. Plast Reconstr Surg 2008; 121 (02) 497-504
  • 15 Masia J, Clavero JA, Larrañaga J, Vives L, Pons G. Preoperative planning of the abdominal perforator flap with multidetector row computed tomography: 3 years of experience. Plast Reconstr Surg 2008; 122 (02) 80e-81e
  • 16 Gaillard J, Bourcheix LM, Masquelet AC. Perforators of the fibular artery and suprafascial network. Surg Radiol Anat 2018; 40 (08) 927-933
  • 17 Loos MS, Freeman BG, Lorenzetti A. Zone of injury: a critical review of the literature. Ann Plast Surg 2010; 65 (06) 573-577
  • 18 Arnez ZM. Immediate reconstruction of the lower extremity--an update. Clin Plast Surg 1991; 18 (03) 449-457
  • 19 Celiköz B, Sengezer M, Işik S. et al. Subacute reconstruction of lower leg and foot defects due to high velocity-high energy injuries caused by gunshots, missiles, and land mines. Microsurgery 2005; 25 (01) 3-14 , discussion 15
  • 20 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
  • 21 Hallock GG. Liability of recipient vessels distal to the zone of injury when used for extremity free flaps. J Reconstr Microsurg 1996; 12 (02) 89-92
  • 22 Freedman AM, Meland NB. Arteriovenous shunts in free vascularized tissue transfer for extremity reconstruction. Ann Plast Surg 1989; 23 (02) 123-128
  • 23 Lin CH, Mardini S, Lin YT, Yeh JT, Wei FC, Chen HC. Sixty-five clinical cases of free tissue transfer using long arteriovenous fistulas or vein grafts. J Trauma 2004; 56 (05) 1107-1117
  • 24 Yazar S, Lin CH. Selection of recipient vessel in traumatic lower extremity. J Reconstr Microsurg 2012; 28 (03) 199-204
  • 25 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 (04) 1109-1111
  • 26 Stompro BE, Stevenson TR. Reconstruction of the traumatized leg: use of distally based free flaps. Plast Reconstr Surg 1994; 93 (05) 1021-1025 , discussion 1026–1027
  • 27 Kolker AR, Kasabian AK, Karp NS, Gottlieb JJ. Fate of free flap microanastomosis distal to the zone of injury in lower extremity trauma. Plast Reconstr Surg 1997; 99 (04) 1068-1073
  • 28 Park S, Han SH, Lee TJ. Algorithm for recipient vessel selection in free tissue transfer to the lower extremity. Plast Reconstr Surg 1999; 103 (07) 1937-1948
  • 29 Stranix JT, Borab ZM, Rifkin WJ. et al. Proximal versus distal recipient vessels in lower extremity reconstruction: a retrospective series and systematic review. J Reconstr Microsurg 2018; 34 (05) 334-340
  • 30 Isenberg JS, Sherman R. Zone of injury: a valid concept in microvascular reconstruction of the traumatized lower limb?. Ann Plast Surg 1996; 36 (03) 270-272
  • 31 Hong JP. The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution. Plast Reconstr Surg 2009; 123 (01) 230-235
  • 32 Albertengo JB, Rodriguez A, Buncke HJ, Hall EJ. A comparative study of flap survival rates in end-to-end and end-to-side microvascular anastomosis. Plast Reconstr Surg 1981; 67 (02) 194-199
  • 33 Cho EH, Garcia RM, Blau J. et al. Microvascular anastomoses using end-to-end versus end-to-side technique in lower extremity free tissue transfer. J Reconstr Microsurg 2016; 32 (02) 114-120
  • 34 Godina M. Preferential use of end-to-side arterial anastomoses in free flap transfers. Plast Reconstr Surg 1979; 64 (05) 673-682
  • 35 Takanari K, Kamei Y, Toriyama K, Yagi S, Torii S. Differences in blood flow volume and vascular resistance between free flaps: assessment in 58 cases. J Reconstr Microsurg 2009; 25 (01) 39-45
  • 36 Sasmor MT, Reus WF, Straker DJ, Colen LB. Vascular resistance considerations in free-tissue transfer. J Reconstr Microsurg 1992; 8 (03) 195-200
  • 37 Ono M, Takanari K, Toriyama K. et al. Effects of tissue component volumes on vascular resistance in free flaps. J Reconstr Microsurg 2017; 33 (01) 32-39
  • 38 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
  • 39 Verhelle NA, Heymans O. How to deal with difficult microsurgical end-to-side anastomoses. Microsurgery 2005; 25 (03) 203-208
  • 40 Hong JPJ, Goh TLH, Choi DH, Kim JJ, Suh HS. The efficacy of perforator flaps in the treatment of chronic osteomyelitis. Plast Reconstr Surg 2017; 140 (01) 179-188
  • 41 Fernandez-Garrido M, Lopez Penha TR, Qiu SS. Flow-through flaps in the absence of an arterial gap for extremity defect reconstruction: minimizing the donor-site morbidity. J Reconstr Microsurg 2019; 35 (05) 329-334
  • 42 Toia F, Zabbia G, Roggio T, Pirrello R, D'Arpa S, Cordova A. Vascular grafts and flow-through flaps for microsurgical lower extremity reconstruction. J Reconstr Microsurg 2017; 33 (Suppl. 01) S14-S19
  • 43 Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 2009; 124 (05) 1529-1544
  • 44 Kim KN, Hong JP, Park SW, Kim SW, Yoon CS. Overcoming the obstacles of the Ilizarov device in extremity reconstruction: usefulness of the perforator as the recipient vessel. J Reconstr Microsurg 2015; 31 (06) 420-425
  • 45 Hong JP, Koshima I. Using perforators as recipient vessels (supermicrosurgery) for free flap reconstruction of the knee region. Ann Plast Surg 2010; 64 (03) 291-293
  • 46 Suh HS, Oh TS, Lee HS. et al. A new approach for reconstruction of diabetic foot wounds using the angiosome and supermicrosurgery concept. Plast Reconstr Surg 2016; 138 (04) 702e-709e
  • 47 Suh HP, Kim Y, Suh Y, Hong J. Multidetector computed tomography (CT) analysis of 168 cases in diabetic patients with total superficial femoral artery occlusion: is it safe to use an anterolateral thigh flap without CT angiography in diabetic patients?. J Reconstr Microsurg 2018; 34 (01) 65-70
  • 48 Suh HS, Oh TS, Hong JP. Innovations in diabetic foot reconstruction using supermicrosurgery. Diabetes Metab Res Rev 2016; 32 (Suppl. 01) 275-280
  • 49 Van Boerum MS, Wright T, McFarland M, Fiander M, Pannucci CJ. Cross-leg flaps for lower extremity salvage: a scoping review. J Reconstr Microsurg 2019; 35 (07) 505-515
  • 50 Manrique OJ, Bishop SN, Ciudad P. et al. Lower extremity limb salvage with cross leg pedicle flap, cross leg free flap, and cross leg vascular cable bridge flap. J Reconstr Microsurg 2018; 34 (07) 522-529