Lower Extremity Composite Free Flaps

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Early composite grafts included free groin flaps with a sheet of external oblique aponeurosis, iliac bone, or abdominal fascia.27-29 Advantages of these groin flaps included the ability to transfer iliac bone with the graft for a calcaneal defect, as well as the location of the donor scar, which was usually hidden by underclothing. Disadvantages included a short and thin superficial circumflex iliac artery pedicle, the need for repair of the external oblique in the donor site with foreign material, and the frequent need for further debulking procedures for a flap that was too thick for the posterior ankle region. Although there was limited dorsiflexion, the results were satisfactory.

Many constructs from thigh donor sites have been developed for reconstruction in the region of the Achilles tendon. One of the first reported is a fascial composite flap that transfers the tensor fascia lata with the lateral femoral cutaneous nerve to create a neurovascular, sensate free flap.30 Another report described a tensor fascia lata fas-ciocutaneous perforator flap in five patients: the lateral femoral cutaneous nerve was included to provide sensation, and the donor site was closed primarily in most patients.31 Several patients underwent further debulking procedures at the ankle. A tensor fascia lata myocutaneous flap has also been described in a patient who required little soft tissue replacement other than the Achilles: the entire iliotibial tract was used to replace the tendon, and skin coverage was cosmetically acceptable.32 A disadvantage of the tensor fascia lata flap is its bulk, which is often too excessive for normal shoes in the narrow distal posterior leg region. The consistency of its vascular pedicle has also been questioned.33

Other procedures involve a free lateral thigh or anterolateral thigh flap with fascia lata sheet (Fig. 23.2).1,34,35 The fascia lata in these flaps is rolled into a cylinder to replace the missing tendon segment. Advantages include a long and relatively large vascular pedicle (the descending branch of the lateral femoral circumflex artery), a large skin paddle of up to 800 cm2, a donor site that can be closed directly if the defect is less than approximately 8 cm, ample subcutaneous fat to permit tendon gliding, and the possibility of including the rectus femoris or vastus lateralis muscle.29 Inclusion of these muscles may be difficult, however: splitting the vastus lateralis longitudinally may jeopardize the blood supply to part of the muscle, and in the case of the rectus femoris, the takeoff of its pedicle is very close to the site of anastomosis on the lateral femoral circumflex. Other disadvantages of the thigh flaps are the anatomic variation and small size of many of the perforators from the lateral femoral circumflex and the profunda femoris, as well as the need for skin grafting the donor site if a large skin paddle is needed.35,36 Although not yet described, it could be possible to construct a sensate flap using the lateral cutaneous nerve of the thigh.

The only composite flap reported from the medial thigh is a gracilis free flap that that was used in one case to reconstruct the Achilles tendon and provide vascularized soft tissue.37 The flap was fitted to the tendon defect by folding the grac-ilis tendon on itself and suturing it to the muscle belly. A skin graft covered the muscle. There was excellent functional restoration of the tendon and an acceptable soft tissue contour.

A successful technique using a fasciocutaneous infragluteal flap has been reported in five patients with very good to excellent results.38 Partial and small complete tendon defects were repaired with the ischiocutaneous ligament of the gluteal crease, and a branch of the posterior cutaneous nerve of the thigh was used to provide sensation. The arterial supply is somewhat variable, and dissection of the nerve can be difficult, but a large amount of soft tissue is available and the hidden donor site can be closed directly.

A dorsalis pedis free flap from the same foot has been reported, which included tendon strips of

Figure 23.2. (A) Design of a 12- by 7-cm composite anterolateral eratively (arrowhead). f = fascia lata graft. (C) Left heel with stable thigh flap including a 6- by 8-cm strip of fascia lata (arrowhead) at coverage 2 years postoperatively. (Reproduced with permission the right thigh. (B) Magnetic resonance images demonstrating from Kuo, et al., 2003, Reference 35.) continuity of the reconstructed Achilles tendon 3 months postop-

Figure 23.2. (A) Design of a 12- by 7-cm composite anterolateral eratively (arrowhead). f = fascia lata graft. (C) Left heel with stable thigh flap including a 6- by 8-cm strip of fascia lata (arrowhead) at coverage 2 years postoperatively. (Reproduced with permission the right thigh. (B) Magnetic resonance images demonstrating from Kuo, et al., 2003, Reference 35.) continuity of the reconstructed Achilles tendon 3 months postop-

extensor digitorum longus and the superficial rior tibial artery would be required to preserve peroneal nerve. Excellent results were obtained blood flow to the foot.

after a second lengthening procedure and protec- An anterior rectus sheath fasciocutaneous free tive sensation was restored to the region, but there flap was successfully used to reconstruct the was limited toe excursion and the dorsalis pedis Achilles tendon and provide skin cover in two donor site required a skin graft.39 A robust poste- patients with infected recipient sites.40 Musculo-

cutaneous flap coverage is superior to fasciocuta-neous flap coverage in the presence of infection.41

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