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

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Flap reconstruction of the lower extremity is a complex process. Read the article to learn about different reconstruction procedures.

Written by

Dr. Pallavi. C

Medically reviewed by

Dr. Jain Vicky Ghewarchand

Published At December 29, 2022
Reviewed AtFebruary 7, 2023

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.

  • 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.

Frequently Asked Questions

1.

What Is Meant by Flap Reconstruction Surgery?

Flap reconstruction surgery, also known as tissue-based reconstruction, is a medical procedure to move healthy and live tissues from one part of the donor site) of the body to another (recipient site). The flap surgery is mainly done in the body areas that have either lost muscle movement, fat, skin, or skeletal support. The surgery is also often used by healthcare professionals to close wounds.

2.

How Successful Is Flap Reconstruction Surgery?

Flap reconstruction surgery is usually considered a safe and reliable procedure in various cases, especially in the head and neck region. The success rate of the surgery is almost 91 to 99 percent. However, about 50 to 60 percent of these patients often develop loco-regional recurrence after flap reconstruction surgery within two years

3.

How Do Graft and Flap Reconstruction Differ From Each Other?

The graft is the transfer of skin without the blood supply, whereas flap reconstruction is a procedure that transfers skin from one part of the body to another with an intact blood supply. Also, the flap allows the use of more significant amounts of tissues, including muscles. Though graft is a straightforward procedure, technically, it is time-consuming because it can create a second surgical site.

4.

Are There Any Risks Associated With Flap Surgery?

The risks associated with flap surgery include:
- Loss of Flap: The blood supply to the flap may get clogged, leading to bleeding. This can cause the death of tissues and cause partial or complete loss of flap. This mostly happens to people, especially women who smoke a lot. Quitting smoke before undergoing flap reconstruction surgery can also be beneficial.
- Issues With the Donar Site: Women usually find wound healing issues after having abdominal flap reconstruction due to fluid buildup.
- Abdominal Buldge or Hernia: This situation usually arises when a person undergoes flap reconstruction, and some part of the bowel emerges from the abdominal wall. This mainly occurs in TRAM (traverse rectus abdominal muscle) flap reconstruction.

5.

Is it Safe to Undergo Flap Reconstruction?

Flap surgery is considered safe for a medically healthy individual. It is a very complex procedure but is mostly considered safe with comparatively fewer associated complications. However, in nutritionally weak patients, caution needs to be taken. But if a person requires flap reconstruction surgery, it cannot be avoided.

6.

Does Flap Surgery Fail?

Though the success rate of flap reconstruction surgery is almost 96 percent, the failure of the process can also occur. The flap surgery usually fails within the first 48 hours of the procedure, but with timely intervention, the situation can be managed effectively, and flap compromise salvage can be possible. 

7.

Which Flap Surgery Is Best for Lower Leg?

The best flap surgery for the lower leg is the soleus muscle flap. This flap reconstruction is considered best for covering the middle and lower leg defects. The soleus muscle flap includes vascular supply from the popliteal artery and the branches of both peroneal arteries (lateral belly) and the posterior tibial (medial belly).

8.

When Is Flap Surgery Recommended to a Person?

The flap surgery is indicated in the following cases:
- Substantial loss of tissue during trauma.
- Loss of tissue due to oncologic resection.
- Persistent inflammation with moderate to deep pockets in an area.
- Root hemisection or resection.
- Irregular bony contour.
- Grade II or III furcation involvement.
- Intrabony pockets on distal area of last molars.
- Complete removal of root irritants is impossible as they are not visible clinically, and the tooth has pockets, too.

9.

What Are the After Effects of a Flap Surgery?

Post-flap reconstruction surgery, a person can feel numbness in the area for several weeks after the procedure. In some cases, inflammation and bleeding can also occur, and there are high chances of infection. A person may also experience wound breakdown, scarring, and damage to nearby structures.

10.

How Much Time Does a Flap Take to Recover?

Flap surgery can heal within a week, and a person can resume normal life activities. Also, after four to five weeks, they can start their physical fitness regime, such as swimming and exercise. However, proper recovery after flap surgery may take up to three months.

11.

Does Flap Surgery Cause Pain?

Pain caused by flap reconstruction surgery is a common condition, and in some cases, people get anxiety attacks due to their perception of pain during the procedure. However, the pain can be relieved by medication and a long healing time.

12.

What Is the Duration of Flap Procedure?

Flap surgery is a complex procedure of skin harvesting, and it may take 10 to 12 hours to perform this complicated surgery. However, flap reconstruction procedures may vary in duration depending upon the type and severity of the condition for which the flap surgery is performed.

13.

Which Medical Speciality Performs Flap Surgery?

Flap surgery is a type of plastic and reconstructive surgery. It is mainly performed by a team of healthcare professionals, including a plastic surgeon, primary physician, anesthesia provider, and a nurse.
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Dr. Jain Vicky Ghewarchand
Dr. Jain Vicky Ghewarchand

plastic surgery-reconstructive and cosmetic surgery

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