Anterolateral thigh flap in the treatment of postburn flexion contractures of the knee

The use of the anterolateral thigh fasciocutaneous flap in the reconstruction of soft-tissue defects around the knee among burn patients is described. The anterolateral thigh fasciocutaneous flap was used for eight patients (all male; mean age, 45 years; age range, 32 to 60 years). Flexion contracture was observed for seven patients with unhealed wounds and one patient with a healed burn wound. The anterolateral thigh flap was used as a free flap for six patients and as a distally based island flap for two patients. The flaps ranged from 8 to 17 cm in width and from 12 to 30 cm in length. Seven flaps were based on a musculocutaneous perforator, and two of them were thinned before transfer to the defect. A true septocutaneous perforator was observed in only one case. The mean follow-up period was 12.5 months (range, 3 to 23 months). Only one flap exhibited distal superficial necrosis, which did not compromise the final result. All patients returned to ambulatory status in 15 to 22 days. Extensor splints were applied to prevent mobilization of the skin graft at the flap donor site for only 7 days. The anterolateral thigh flap has many advantages for the reconstruction of postburn flexion contracture of the knee, as follows: (1) very large thin flaps can be elevated, (2) the two-team approach is possible, (3) color and texture matches are good, (4) the donor-site scar can be easily hidden, and (5) the technique allows early mobilization and patients can return to normal daily activity in a short time. Free or distally based anterolateral thigh flaps are a good choice, both aesthetically and functionally, for the reconstruction of soft-tissue defects of the knee region.     

Simultaneous multiple toe transfers in hand reconstruction

Our experience with simultaneous transfer of two or more toe units to the same hand where multiple digits were missing is presented. Forty-six toes from 38 feet were transferred to reconstruct 19 hands in 19 patients. The transfers consisted of 7 combined second and third toe units and 32 single toes. Three patients had a primary and 16 patients had a secondary reconstruction. There was one complete and one partial failure. The two-point discrimination ranged from 6 mm to protective sensation. Total active movement averaged 57 degrees in the thumb and 127, 93, 71, and 68 degrees, respectively, in the fingers reconstructed at middle phalanx, proximal phalanx, metacarpophalangeal joint, and metacarpal head. Pulp-to-pulp pinch averaged 2.4 kg in patients who had thumbs reconstructed and averaged 3.0 kg in patients who had normal thumbs. There was no cold intolerance, and no significantly disabled foot occurred except one with scissoring deformity. Simultaneous multiple toe transfer in hand reconstruction is feasible without increased complications both in primary and secondary wound conditions. It is time-effective and cost-effective.     

Reconstruction of the weight-bearing surface of the foot with nonneurosensory free flaps

Neurotized fasciocutaneous flaps and split-skin grafted muscle flaps are the most frequently used free flap alternatives for the reconstruction of weight-bearing surfaces of the foot. An objective comparison of the innate characteristics of these two flap types, with respect to long-term stability, has not been possible because sensory reinnervation in the fasciocutaneous flaps has been a confounding factor. This study compares nonsensate fasciocutaneous flaps (n = 9) with nonsensate split-skin grafted muscle flaps (n = 11), with mean follow-up periods of 34.3 and 31.3 months, respectively. Patients completed a form that included questions regarding degree of pain at the operative site, presence of ulcers, ability to wear normal shoes, employment status, and time spent standing on foot. Touch and deep sensation were evaluated with Semmes-Weinstein and vibration tests, respectively. Significantly less pain and less ulceration (p < 0.05) were observed in the fasciocutaneous group. Semmes-Weinstein monofilament tests revealed poorer results with split-skin grafted muscle flaps, compared with fasciocutaneous flaps. These results indicate that even if the sensory protection of fasciocutaneous flaps is not considered, these flaps have superior properties, compared with split-skin grafted muscle flaps.     

Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps

The free anterolateral thigh flap is becoming one of the most preferred options for soft-tissue reconstruction. Between June of 1996 and August of 2000, 672 anterolateral thigh flaps were used in 660 patients at Chang Gung Memorial Hospital. Four hundred eighty-four anterolateral thigh flaps were used for head and neck region recontruction in 475 patients, 58 flaps were used for upper extremity reconstruction in 58 patients, 121 flaps were used for lower extremity reconstruction in 119 patients, and nine flaps were used for trunk reconstruction in nine patients. Of the 672 flaps used in total, a majority (439) were musculocutaneous perforator flaps. Sixty-five were septocutaneous vessel flaps. Of these 504 flaps, 350 were fasciocutaneous and 154 were cutaneous flaps. Of the remaining 168 flaps, 95 were musculocutaneous flaps, 63 were chimeric flaps, and the remaining ten were composite musculocutaneous perforator flaps with the tensor fasciae latae. Total flap failure occurred in 12 patients (1.79 percent of the flaps) and partial failure occurred in 17 patients (2.53 percent of the flaps). Of the 12 flaps that failed completely, five were reconstructed with second anterolateral thigh flaps, four with pedicled flaps, one with a free radial forearm flap, one with skin grafting, and one with primary closure. Of the 17 flaps that failed partially, three were reconstructed with anterolateral thigh flaps, one with a free radial forearm flap, five with pedicled flaps, and eight with primary suture, skin grafting, and conservative methods.In this large series, a consistent anatomy of the main pedicle of the anterolateral thigh flap was observed. In cutaneous and fasciocutaneous flaps, the skin vessels (musculocutaneous perforators or septocutaneous vessels) were found and followed until they reached the main pedicle, regardless of the anatomic position. There were only six cases in this series in which no skin vessels were identified during the harvesting of cutaneous or fasciocutaneous anterolateral thigh flaps. In 87.1 percent of the cutaneous or fasciocutaneous flaps, the skin vessels were found to be musculocutaneous perforators; in 12.9 percent, they were found as septocutaneous vessels. The anterolateral thigh flap is a reliable flap that supplies a large area of skin. This flap can be harvested irrespective of whether the skin vessels are septocutaneous or musculocutaneous. It is a versatile soft-tissue flap in which thickness and volume can be adjusted for the extent of the defect, and it can replace most soft-tissue free flaps in most clinical situations.     

Fist position for skin grafting on the dorsal hand: I. Analysis of length of the dorsal hand surgery in hand positions.

In skin grafting for reconstruction of burns and contracture deformities of the dorsal hand, the hand is kept in a proper position to provide the greatest amount of skin and to avoid the secondary functional deformity. The safe position has been commonly used for immobilizing the hand, but this is to protect the hand function rather than to provide maximal surface for skin grafting. Split-thickness skin graft contracts up to 30 to 50 percent of the original size owing to secondary contraction. If insufficient skin is grafted, contracture deformity of the dorsal hand may occur. To graft the greatest amount of skin on the dorsal hand, the hand should be kept preoperatively in a position flexing all joints of the wrist, metacarpophalangeal joints, and interphalangeal joints and maximally stretching the dorsal hand (a fist position). We studied the surface length of the dorsal hand between the wrist, the metacarpophalangeal joint, and the eponychium in the anatomic, safe, and fist positions of the right hand in 60 adults. Difference of total length between the anatomic and safe positions was not statistically significant (p > 0.05). The total length in a fist position was significantly increased in comparison with the other two positions (p < 0.05). In a fist position compared with the safe position, the increase in length of the dorsal surface of the proximal hand was 11 to 20 percent except in the thumb, and the increase in length of the dorsal surface of the finger was 12 to 17 percent. The increase in total length of a fist position was about 9 mm (7 to 8 percent) in the thumb and 20 to 32 mm (14 to 18 percent) in the index to little fingers. It suggests that the safe position fails to provide an increased dorsal hand surface area for skin grafting compared with the anatomic position. The greatest amount of skin can be grafted in a fist position. Hand immobilization in a fist position for 7 to 9 days after skin grafting has not resulted in irrevocable joint stiffness in our experience. If injury of the deep structures is not present, the hand should be immobilized in a fist position before skin grafting on the dorsal hand.     

The basic types of scar contractures after burns and methods of eliminating them with trapezeplasty flaps

The study of postburn scar contractures in various locations has revealed four contracture variables: edge, medial, strip, and total. Following the surgical treatment of more than 2000 patients with such contractures, a trapezeplasty flap method has been worked out and applied since 1979. This method allows one to make up for deficient scar tissue of the same shape. Flaps are cut out of sheets of a fold with the maximum use of undamaged skin in adjacent sections. They move toward each other and merge with adjacent sides into a state of tension. This surgery is based on use of the reserve on the width of the surface of a fold and the high tension of skin with pressure on underlying tissue. The extended skin grows quickly, the tension disappears, and the scars dissolve. For each contracture type, there are trapeze-flap variables either in pure form or in combination with the transposition of split-thickness skin with a flap to create a flexible joint zone. The trapezeplasty flap method can be used to treat all edge, medial, strip, and total contractures of joints whose natural position is adduction, the shoulder joint, and contractures between fingers. Skin-fat or skin-fascia trapeze flaps prevent the relapse of contracture and make the weakened scars softer, which, as a rule, ensures a good functional and aesthetic result.     

The radial forearm skin graft-fascial flap

The radial forearm flap has become a versatile flap for upper extremity reconstruction. The use of the forearm flap for hand reconstruction in the patient with previously burned forearms has not been widely appreciated. In those patients whose forearms have been previously split-thickness skin-grafted on fascia, we have employed the reverse radial forearm flap as a skin graft-fascial flap for hand reconstruction and have obtained excellent functional results. Three patients at various intervals postburn are presented to demonstrate use of this flap for wrist contracture release, coverage of arthroplasties, first web space contracture release, and acute salvage of phalanges and tendons. Assessment of the hand's vascular anatomy and careful treatment of the donor area have contributed to no added morbidity and an excellent aesthetic result at the donor site.     

Reconstruction of the thumb with a trimmed-toe transfer technique

The trimmed-toe transfer is a new modification of the existing great-toe transfer technique for thumb reconstruction. This procedure was devised to circumvent patient concerns regarding overly large reconstructed digits following total great-toe-to-hand transfer. This technique involves reduction of both the bony and soft-tissue elements along the medial aspect of the transferred great toe in order to produce a more normal sized thumb. Follow-up of the initial 20 patients from 1983 to 1986 demonstrates good stability, grip strength, and pinch strength. Although compared with total great-toe transfer a modest reduction in joint motion of trimmed toes has been observed, the overall appearance and usefulness of the reconstructed thumbs have been excellent.     

Reliability of inferior pedicle reduction mammaplasty in burned oversized breasts

Heavy pendulous breasts cause physical and psychological trauma. Postburn deformity of breasts results in significant asymmetry, displacement of nipple-areola complex, due to burn scar contracture, and significant scarring; these factors add more psychological discomfort and subsequent behavioral changes. The use of the inferior pedicle procedure in burned breasts can solve many problems. The technique reduces the size of the large breast, eliminates the scar tissue by excising both medial and lateral flaps, and brings the mal-located nipple and areola to a normal position. This study stresses the possibility of harvesting the inferior dermal pedicle flap from within the postburn scar tissue without necrosis of the nipple and areola, because of the excellent flap circulation. Acceptable aesthetic appearance and retainment of nipple viability and sensitivity can be achieved with the inferior pedicle technique even with postburn deformity of the breast. The study was conducted on 11 women, all of whom had sustained deep thermal burns to the breasts and anterior torso and whose breasts were hypertrophied and pendulous.     

Grasping behavior in tufted capuchin monkeys (Cebus apella): grip types and manual laterality for picking up a small food item

This study investigates prehension in 20 tufted capuchins (Cebus apella) in a reaching task requiring individuals to grasp a small food item fixed to a tray. The aim was twofold: 1) to describe capuchins' grasping techniques in detail, focusing on digit movements and on different areas of contact between the grasping fingers; and 2) to assess the relationship between grip types and manual laterality in this species. Capuchins picked up small food items using a wide variety of grips. In particular, 16 precision grip variants and 4 power grip variants were identified. The most frequently used precision grip involved the distal lateral areas of the thumb and the index finger, while the most preferred kind of power grip involved the thumb and the palm, with the thumb being enclosed by the other fingers. Immature capuchins picked up small food items using power grips more often than precision grips, while adult individuals exhibited no significant preference for either grip type. The analysis performed on the time capuchins took to grasp the food and withdraw it from the tray hole revealed that 1) precision grips were as efficient as power grips; 2) for precision grips, the left hand was faster than the right hand; and 3) for power grips, both hands were equally quick. Hand preference analysis, based on the frequency for the use of either hand for grasping actions, revealed no significant hand bias at group level. Likewise, there was no significant relationship between grip type and hand preference.     

Free split-cutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects

With recent advances in free-tissue transfer, microsurgical techniques have been used more frequently for the reconstruction of postburn contracture defects. Traditional methods, including full-thickness skin grafts and local flaps, often result in a good outcome; however, multiple operative procedures, long periods of splinting, and physical rehabilitation are often required. Free split-cutaneous perforator flaps, consisting of one large cutaneous paddle with two perforating vessels split into two separate skin regions, were used for two kinds of postburn contractures: rectangular and spatially separate defects. From September of 2000 to October of 2002, seven patients underwent this method of reconstruction at Chang Gung Memorial Hospital in Taiwan. A three-dimensional flap harvest method, in which the skin paddle is circumferentially elevated early in the harvest, was used. Postburn scar contractures had resulted from flame burns in six cases and an electric burn in one case. The reconstructive regions included the neck in two patients, the breast in one patient, and the hand in four patients. There were six male patients and one female patient, with a mean age of 34.8 years (range, 25 to 49 years). The size of the excised scar ranged from 120 cm2 to 308 cm2 (mean, 162.3 cm2). The size of the unsplit flaps ranged from 144 cm2 to 337.5 cm2 (mean, 192.1 cm2). The average time for flap harvest using this three-dimensional harvest technique was 39.1 minutes. The average total operative time was 4.3 hours. The average total hospital stay was 7.3 days (range, 6 to 11 days). All flaps survived without major complications. The donor site was closed primarily in all cases. At a mean follow-up time of 9 months, the functional and aesthetic outcomes showed significant improvement as compared with the preoperative condition. In this study, a new method of flap harvest using a three-dimensional technique is introduced, and its application in the reconstruction of postburn contractures is evaluated.     

Extending the reach of the heterodigital arterialized flap by vein division and repair

The heterodigital arterialized flap is ideal for nonsensory reconstruction of sizable soft-tissue defects in the proximal fingers, web spaces, and the hand. The inclusion of a dorsal vein augments the venous drainage of this digital island flap and avoids the problem of postoperative venous congestion, which is a common problem in digital island flaps. However, the presence of a dorsal vein pedicle inhibits flap mobility somewhat, and the reach of the flap is mainly limited to adjacent fingers. In situations that demand a transfer from a nonadjacent donor finger or when the reach from the adjacent donor finger is inadequate, the dorsal vein pedicle can be temporarily divided and then anastomosed microsurgically after flap transfer is performed. This enables the reach of the flap to be extended up to two fingers from the donor finger. The authors performed this "partially free" heterodigital arterialized flap in 11 consecutive patients between 1991 and 2001. The average size of the defects was 4.4 x 2.3 cm. All of the flaps survived completely, without any evidence of postoperative flap congestion. Healing of all of the flaps was primary and did not result in any scarring. All of the donor fingers had "normal" two-point discrimination of 3 to 5 mm. All of the donor fingers retained excellent or good total active motion, as graded by the criteria of Strickland and Glogovac.     

Rheumatoid arthritis and Dupuytren's contracture

Of four patients with rheumatoid arthritis and Dupuytren's contracture, two were not aware of the presence of Dupuytren's contracture. When both diseases coexist, the presence of rheumatoid hand deformities, especially flexion and ulnar deviation of the metacarpophalangeal joints, may mask the flexion deformity caused by Dupuytren's contracture. Careful clinical examination should rule out the presence of a pathologic fascial cord. When reconstructive surgery is indicated for the rheumatoid hand in the presence of advanced Dupuytren's contracture, staged surgery would be appropriate and reconstruction of Dupuytren's contracture should precede other surgery.     

The expanded transposition flap: shifting paradigms based on experience gained from two decades of pediatric tissue expansion

The authors present their experience with the design of expanded skin flaps gained over the past two decades in a large series of 995 expanded flap reconstructions performed in 626 operations in 430 patients. The indications for tissue expansion were giant congenital pigmented nevi (72.7 percent), scar contractures (11.2 percent), and a remainder for a variety of congenital and acquired deformities. Surgical strategies were reviewed retrospectively to determine the location in the body where the tissue expansion was performed, the number of procedures required to accomplish the reconstructive goal, and the design of the expanded flap that was used to reconstruct the involved area. Specific points that were noticed included contour deformities (such as webbing, dog-ears, or decreased limb circumference) following flap reconstruction, anatomic distortions (such as distortion of the eyebrow or the distance from the brow to hairline) following reconstruction, final position of the scars in relation to anatomic landmarks, borders of aesthetic units, and relaxed skin tension lines, and the potential for later scar contracture. Careful examination of reconstruction by region of involvement demonstrated significant advantages in the use of expanded transposition flaps over pure advancement. These advantages and the modifications in the design of expanded flaps for each body region are discussed in a series of representative cases. They emphasize the ability of transposition flaps to dissipate tension away from the flap apex and distribute it more proximally, thus redirecting the tension lines so there is less likelihood of anatomic distortion in the reconstructed area. Also, flaps designed in this manner allow improved contour by avoiding webbing, tenting across concavities, and bunching of skin laterally. The authors conclude that restricting the expanded flap design to advancement alone to minimize potential scarring severely limits the reconstructive capabilities of the added tissue and distracts from the surgeon's ability to accomplish the initial reconstructive goal. The cost of additional incisions is worthwhile to achieve better final contour of the reconstructed part, lesser risk of anatomic distortion, better position of the scars, and lowered risk of scar contracture.     

Triple coverage of ischial ulcers with adipofascial turnover and fasciocutaneous flaps

Despite a wide variety of flap options, ischial ulcers remain the most difficult pressure ulcers to treat. This article describes the authors' successful surgical procedure for coverage of ischial ulcers using adipofascial turnover flaps combined with a local fasciocutaneous flap. After debridement, the adipofascial flaps are harvested both cephalad and caudal to the defect. The flaps are then turned over to cover the exposed bone in a manner so as to overlap the two flaps. A local fasciocutaneous flap (Limberg flap) is applied to the raw surface of the turnover flaps. Twenty-two patients with ischial ulcers were treated using this surgical procedure. Overall, 86.4 percent of the flaps (19 of 22) healed primarily. Triple coverage with the combination of double adipofascial turnover flaps and a local fasciocutaneous flap allows for an easily performed and minimally invasive procedure, preservation of future flap options, and a soft-tissue supply sufficient for covering the prominence and bony prominence and filling dead space. This technique provides successful soft-tissue reconstruction for minor to moderate-size ischial pressure ulcers.     

Heterodigital arterialized flaps for large finger wounds: results and indications

Deep defects of the hand and fingers with an unhealthy bed exposing denuded tendon, bone, joint, or neurovascular structures require flap coverage. However, the location and size of the defects often preclude the use of local flap coverage. Free-flap coverage is often not desirable either, because the recipient vessels may be unhealthy from surrounding infection or trauma. In such situations, a regional pedicled flap is preferable. A solution to this is the heterodigital arterialized flap. This flap is supplied by the digital artery and a dorsal vein of the finger for venous drainage. Unlike the neurovascular island flap, the digital nerve is left in situ in the donor finger, thus avoiding many of the neurologic complications associated with the Littler flap. The digital artery island flap is centered on the midlateral line of the donor finger. It extends from the middorsal line to the midpalmar line. The maximal length of the flap is from the base of the finger to the distal interphalangeal joint. By preserving the pulp and the digital nerve, a sensate pulp on the donor finger remains that reduces donor-finger morbidity and also preserves fingertip cosmesis. Twenty-nine flaps were performed in 29 patients and the outcomes in the donor finger and the reconstructed finger were reviewed. The flap survival was 100 percent. There were no cases of flap ischemia or flap congestion. Good venous drainage of the flap through the additional dorsal vein was helpful in preventing the occurrence of early postoperative venous congestion, which is common in island flaps of the fingers, which depend on only the venae comitantes for drainage. Donor-finger morbidity, measured in terms of range of motion and two-point discrimination in the pulp, was minimal. Ninety-seven percent of the donor fingers achieved excellent or good total active motion according to the criteria of Strickland and Glogovac. Pulp sensation in the donor fingers was normal in 28 of the 29 donor fingers. No cold intolerance of the donor finger or the adjacent finger is reported in this series.     

Treatment of ischial pressure ulcers with a posteromedial thigh fasciocutaneous flap.

This study describes the use of the posteromedial thigh fasciocutaneous flap for the treatment of ischial pressure sores. The authors prefer this flap because it is the fasciocutaneous flap nearest to the ischial region, it is easy to raise, and it causes no donor-site morbidity. In this study, 11 ischial pressure sores in 10 paraplegic patients were closed using the posteromedial thigh fasciocutaneous flaps. All flaps survived, although two caused distal necrosis; after these same two flaps were readvanced, they survived. After an average follow-up time of 77 months, seven of the 10 patients have had no recurrence of ulcers.This fasciocutaneous flap was previously described by Wang et al. However, this study revealed that the arrangement of the vascular pedicle was different from that described by Wang et al. To reveal the vascular supply of this flap, anatomic dissections were conducted. The source of circulation to this flap was the suprafascial vascular plexus, in addition to the musculocutaneous perforator. The dominant pedicle was the musculocutaneous perforator from either the adductor magnus muscle or the gracilis muscle. The key to safe elevation of this flap was the accurate outlining of the skin island directly over the vascular pedicle and the preservation of the proximal fascial continuity. Of the 11 flaps, two viability problems occurred. These partial flap losses resulted from the failure to properly include the perforator. It is the authors' conclusion that the width of the flap should be greater than 5 cm. In addition, it is safe to make a flap within a 1:3 base-to-length ratio in a fatty, diabetic patient. This posteromedial thigh fasciocutaneous flap was found to be a valuable alternative for reconstruction of primary or recurrent ischial pressure ulcers.     

Reconstruction of large sacral defects following total sacrectomy

Total sacrectomies for cancer ablation often result in extensive defects that are challenging to reconstruct. In an effort to elucidate the criteria to select the most effective reconstructive options, we reviewed our experience with the management of large sacral wound defects. All patients who had a sacral defect reconstruction after a total sacrectomy at our institution between January of 1993 and August of 1998 were reviewed. The size of the defect, the type of reconstruction, postoperative complications, and functional outcome in each patient were assessed. A total of 27 flaps were performed in 25 patients for sacral defect reconstruction after a total sacrectomy. Diagnoses consisted of chordoma (n = 13), giant cell carcinoma (n = 2), sarcoma (n = 5), rectal adenocarcinoma (n = 4), and radiation induced necrosis (n = 1). The size of sacral defects ranged from 18 to 450 cm2 (mean, 189.8 cm2). Ten patients, including five who had preoperative radiation therapy, underwent transpelvic vertical rectus abdominis myocutaneous (VRAM) flap reconstruction for sacral defects with a mean size of 203.3 cm2. Of these, five patients (50 percent) had complications (four minor wound dehiscences and one seroma). Eight patients, including one who had preoperative radiation therapy, underwent bilateral gluteal advancement flap reconstruction for sacral defects with a mean size of 198.0 cm2. They had no complications. Two patients, both of whom had preoperative radiation therapy, underwent gluteal rotation flap reconstruction for sacral defects of 120 cm2 and 144 cm2. Both patients had complications (one partial flap loss and one nonhealing wound requiring a free flap). Three patients, including one who had preoperative radiation therapy, underwent reconstruction with combined gluteal and posterior thigh flaps for sacral defects with a mean size of 246 cm2; two of these patients had partial necrosis of the posterior thigh flaps. Three patients, all of whom had preoperative radiation therapy, underwent free flap reconstruction for sacral defects with a mean size of 144.3 cm2. They had no complications. Our experience suggests that there are three reliable options for the reconstruction of large sacral wound defects: bilateral gluteal advancement flaps, transpelvic rectus myocutaneous flaps, and free flaps. In patients with no preoperative radiation therapy and intact gluteal vessels, the use of bilateral gluteal advancement flaps should be considered. In patients with a history of radiation to the sacral area and in patients whose gluteal vessels have been damaged, the use of the transpelvic VRAM flap should be considered. If the transpelvic VRAM flap cannot be used because of previous abdominal surgery, a free flap should be considered as a last option.     

Role of microsurgery in lower extremity reconstruction

Developments in reconstructive microsurgery have heralded a new phase of limb-saving procedures. Although pedicled local fasciocutaneous or muscle flaps continue their useful role, microsurgical free tissue transfer is usually required for larger defects and also for areas without locoregional options. As this treatment modality has become more established, innovation and technical refinements have resulted in an evolution of flap surgery, including perforator and free-style free flaps, that has been applied to lower limb surgery. Effective outcome measures, bioelectronic prostheses, and composite tissue allotransplantation are the three major trends leading into a new era of lower limb reconstruction. This article outlines the role of microsurgical free tissue transfer for lower limb salvage and reconstruction.     

The concept of fillet flaps: classification, indications, and analysis of their clinical value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the "spare parts" concept.By definition, fillet flaps are axial-pattern flaps that can function as composite-tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects.From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps).Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytren's contracture, and two with high-voltage electrical injuries).Thirty-six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above-knee or below-knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet-of-thigh or entire-limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper-arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet-of-sole flap. In another case, wound infection required revision and above-knee amputation with removal of the flap.Nine free plantar fillet flaps were performed-five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper-arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one above-knee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery.Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients.On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor-site morbidity and facilitate stump-length preservation or limb salvage.