Flap Reconstruction of Lower Extremity - Types, Indications, Procedure, and Complications

Introduction:

Human legs commonly referred to as lower extremities comprise the foot, legs, thigh, and gluteal region. They are essential to maintain balance and locomotion. Reconstruction of lower extremities is often challenging and is necessary to establish the functionality. Reconstruction's primary aim is to preserve limbs along with form and function.

What Are the Causes of Lower Extremity Dysfunction?

• Trauma or injury.

• Accident.

• Malignancy.

• Congenital disorders.

• Infections.

• Degenerative diseases.

• Chronic illness.

Why Is Flap Reconstruction Needed?

Flap reconstruction is needed to achieve the following:

• Restoration of form and function.

• Proper soft tissue coverage for the nourishment of bone.

• Rehabilitation of muscles and joints with flexible movement.

• Proprioception.

• Aesthetic purpose.

How Is Reconstruction Done?

1) Physical Examination:

• This procedure involves inspection of the wound, assessing the loss of tissue, the presence of any infection, and vascular supply to surrounding structures.

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• Apart from the wound, the surrounding structures are also evaluated for any injury or loss of sensation caused by accidents, debilitating diseases, or edema.

• Once the proper examination is done, the surgeon will debride the site and suggest the treatment best suited for patients.

2) Patient Evaluation:

These include

• Patient age and body mass assess the recovery; the younger the age, the greater the recovery.

• The presence of chronic debilitating diseases such as diabetes causes delayed wound healing and chances of infection due to poor blood perfusion.

• Habits such as smoking.

• Underlying systemic diseases like cardiac and respiratory diseases require attention as they impact rehabilitation.

• Dietary habits such as nutrition play an essential role in recovery and reconstruction.

3) Patient needs and desires:

These include

• Expectations of the patients regarding the outcome of surgery, like rehabilitation of the limb to maintain the function with the least importance to aesthetics or proper rehabilitation along with aesthetics.

• Cost of surgery.

• Concern about complications.

• Need for an experienced surgeon.

4) Preoperative Preparation:

• Before the procedure, the surgeon will evaluate the design of the flap. The length of the flap is usually higher to avoid tension.

• The surgical site is cleaned, and a sterile environment is created.

• A tourniquet is tied above the surgical procedure to provide a bloodless environment.

Who Will Do the Surgery?

• An experienced plastic surgeon who is a trauma specialist.

• Generally, this surgery is done simultaneously with bone fixation involving an orthopedic surgeon.

• Once the bony fixation is done, the flap surgery is done immediately or preferably within a week.

What Is a Flap Reconstruction?

Flap reconstruction is a procedure in which tissue is surgically removed and transferred from one part of the body to another for reconstruction purposes. Sometimes tissue is removed along with its blood supply (artery and vein) and transplanted to the desired site.

What Are Different Types of Flaps Used In Reconstruction of Lower Extremity?

Depending on the defect, the surgeon will decide on the treatment plan. If the fault is minor without any exposed bone and tendon, the surgeon will close it using dermal substitutes, primary closure, or secondary intention.

However, if defects are more significant, they may require flap reconstruction.

Two types of flaps are commonly used in the reconstruction of lower extremities. They are:

• Local flaps.

• Free flaps.

1) Local Flap: This involves the removal of tissue from one part of the body (donor site) to other parts of the body. This type of flap does not carry the blood supply. It is usually disconnected from its blood supply and reconnected to a new one.

2) Free Flaps: This involves the removal of tissue along with blood supply from the donor site and transfer to the recipient site.

There are three types of flaps which can be either local or free flaps.

• Fasciocutaneous flap.

• Muscle flap or musculocutaneous flap.

• Newer flap.

Fasciocutaneous Flap:

These flaps usually include skin, subcutaneous tissue, and deep fascia.

• Groin flap: This is one of the earliest used flaps and provides a substantial amount of fascia and tissue. As it is a hair-bearing area, the aesthetics are poor. The short venous supply also increases the chances of failure.

• Medial Thigh: This is commonly referred to as the anterior-medial thigh flap. This flap helps to cover the wounds in the groin, thigh, and perineum.

• Lateral Thigh: This is used in proximal regions on the septum axis dividing the vastus lateralis and the rectus femoris. A 7x20 centimeter skin can be raised from the donor area.

• Sural flap: This is used in the reconstruction of the knee, the anterior and posterior and upper third of the leg, and proximal defects of the legs.

Muscle Flap or Musculocutaneous Flap:

• Gluteus Maximus Flap: The rich vascular network of the gluteal and posterior thigh region provides a more extensive range of flaps for reconstructive surgery. These are used either for anterior or posterior defects.

• Tensor Fascia Lata covers The proximal lower limb and iliac bone.

• Soleus: Used for defects of the middle third of the leg.

• Gastrocnemius: Used for the distal femur, proximal tibia, and knee coverage.

Newer Flap:

Propeller Flap

• Propeller flaps have developed into a desirable choice for covering various flaws.

• Propeller flaps are more flexible in design than typical flaps. They have a more reliable vascular pedicle, which increases the likelihood that challenging wounds can be repaired using local tissues with minor donor-site morbidity.

• Additionally, they enable one-stage reconstruction of abnormalities that typically call for several treatments.

• These propeller flaps help in rotation up to 90 degrees.

Postoperative Care By the Patient:

• Patients should continue the medications and should not miss follow-up appointments.

• Restrict physical activities.

• Adapting healthy lifestyle habits and quitting smoking and tobacco products if the practice is present.

• Patients should report to the doctor immediately if there is a blood clot within 48 hours of surgery.

Complications:

• Blood clots.

• Partial flap necrosis.

• Delayed wound healing.

• Wound dehiscence.

• Failure of the flap.

Conclusion:

Both local and free flap repair can help to preserve lower extremities. However, reconstruction continues to be difficult because it is linked to a disproportionately high rate of postoperative problems. Many patients presenting with lower extremities abnormalities have concomitant conditions affecting their surgical recovery. Therefore a careful selection of the reconstructive process along with the patient's functional goal and possible complications should be considered.